Healthcare Provider Details

I. General information

NPI: 1699773770
Provider Name (Legal Business Name): JAY M WYLAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 12TH PL SE
SALEM OR
97302-2576
US

IV. Provider business mailing address

2605 12TH PL SE
SALEM OR
97302-2576
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-4281
  • Fax: 503-585-7427
Mailing address:
  • Phone: 503-585-4281
  • Fax: 503-585-7427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6637
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: