Healthcare Provider Details

I. General information

NPI: 1891902250
Provider Name (Legal Business Name): THOMAS B WYLIE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 FETNER DR
AMERICUS GA
31709-3774
US

IV. Provider business mailing address

1108 FETNER DR P O BOX 763
AMERICUS GA
31709-3774
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-4479
  • Fax: 229-924-4391
Mailing address:
  • Phone: 229-924-4479
  • Fax: 229-924-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0007667
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: