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General NPI Number Information
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NPI Number | 1003978602
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Entity Type | Individual
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Provider Name | GARY L WYATT DDS
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Gender | Male
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1801 NEWPORT BOULEVARD SUITE C
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City | COSTA MESA
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State | CA
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Zip | 92627
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Country | US
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Telephone | 949-650-1030
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Fax | 949-722-2481
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Provider Business Mailing Address
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Address Line | 1401 AVOCADO AVENUE SUITE 506
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City | NEWPORT BEACH
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State | CA
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Zip | 92660
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Country | US
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Telephone | 949-760-1661
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Fax | 949-760-8016
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 22313
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License Number State | CA
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