Healthcare Provider Details

I. General information

NPI: 1154442572
Provider Name (Legal Business Name): BRIAN L WYCHE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 09/05/2007

III. Provider practice location address

1305 EAST KIRK
HUGO OK
74743
US

IV. Provider business mailing address

1305 EAST KIRK
HUGO OK
74743
US

V. Phone/Fax

Practice location:
  • Phone: 580-326-9631
  • Fax: 580-326-5440
Mailing address:
  • Phone: 580-326-9631
  • Fax: 580-326-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number73368
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: