Healthcare Provider Details

I. General information

NPI: 1598805590
Provider Name (Legal Business Name): DUSTIN ALAN WYLAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST
ROBINS AFB GA
31098-2227
US

IV. Provider business mailing address

3500 HARBISON DR APT 536
VACAVILLE CA
95687-3917
US

V. Phone/Fax

Practice location:
  • Phone: 503-309-4605
  • Fax:
Mailing address:
  • Phone: 503-309-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8863
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: