Healthcare Provider Details

I. General information

NPI: 1801051503
Provider Name (Legal Business Name): TRACY D WYATT DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 W LAKE MEAD BLVD SUITE 6
LAS VEGAS NV
89128-1001
US

IV. Provider business mailing address

7550 W LAKE MEAD BLVD SUITE 6
LAS VEGAS NV
89128-1001
US

V. Phone/Fax

Practice location:
  • Phone: 702-242-9777
  • Fax:
Mailing address:
  • Phone: 702-242-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-163
License Number StateNV

VIII. Authorized Official

Name: DR. TRACY D WYATT
Title or Position: PRESIDENT
Credential: DDS
Phone: 702-242-9777