Healthcare Provider Details

I. General information

NPI: 1780159608
Provider Name (Legal Business Name): WYATT LOFLIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2018
Last Update Date: 10/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9221 CHAMBERLAYNE RD
MECHANICSVILLE VA
23116-2511
US

IV. Provider business mailing address

304 TUCKAHOE BLVD
RICHMOND VA
23226-2134
US

V. Phone/Fax

Practice location:
  • Phone: 894-427-7420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401415924
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: