Healthcare Provider Details

I. General information

NPI: 1073139937
Provider Name (Legal Business Name): WYLIE DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COOPER DR STE 140
WYLIE TX
75098-3969
US

IV. Provider business mailing address

600 COOPER DR STE 140
WYLIE TX
75098-3969
US

V. Phone/Fax

Practice location:
  • Phone: 646-662-3105
  • Fax:
Mailing address:
  • Phone: 646-662-3105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW XU
Title or Position: MEMEBER MANAGER
Credential: DDS
Phone: 646-662-3105