Healthcare Provider Details

I. General information

NPI: 1801889209
Provider Name (Legal Business Name): MARK WIATT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N DATE ST
T OR C NM
87901-3701
US

IV. Provider business mailing address

255 HWY 187 PO BOX 370
HATCH NM
87937-0730
US

V. Phone/Fax

Practice location:
  • Phone: 505-267-3088
  • Fax: 505-267-1747
Mailing address:
  • Phone: 505-267-3088
  • Fax: 505-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD-2602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: