Healthcare Provider Details

I. General information

NPI: 1861898637
Provider Name (Legal Business Name): WYLIE ORTHODONTIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CENTRAL EXPY #1107
RICHARDSON TX
75080-5332
US

IV. Provider business mailing address

100 N CENTRAL EXPY #1107
RICHARDSON TX
75080-5332
US

V. Phone/Fax

Practice location:
  • Phone: 972-907-9900
  • Fax:
Mailing address:
  • Phone: 972-907-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateTX

VIII. Authorized Official

Name: MISS ZELINA TURNER
Title or Position: INSURANCE AND FINANCE COORDINATOR
Credential:
Phone: 972-907-9900