Healthcare Provider Details

I. General information

NPI: 1013021039
Provider Name (Legal Business Name): WAYNE NOLAN WYATT DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9840 E 81ST ST STE 100
TULSA OK
74133-4583
US

IV. Provider business mailing address

9840 E 81ST ST STE 100
TULSA OK
74133-4583
US

V. Phone/Fax

Practice location:
  • Phone: 918-496-1155
  • Fax: 918-496-1167
Mailing address:
  • Phone: 918-496-1155
  • Fax: 918-496-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number151
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5563
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: