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General NPI Number Information
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NPI Number | 1124143896
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Entity Type | Organization
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Legal Business Name | DAVID D. WYSE, D.D.S., P.C.
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 10/03/2013
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Provider Practice Location Address
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Address Line | 207 S PROSPECT RD STE. 2
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City | BLOOMINGTON
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State | IL
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Zip | 61704-4905
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Country | US
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Telephone | 309-663-6393
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Fax | 309-664-0366
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Provider Business Mailing Address
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Address Line | 207 S PROSPECT RD STE. 2
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City | BLOOMINGTON
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State | IL
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Zip | 61704-4905
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Country | US
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Telephone | 309-663-6393
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Fax | 309-664-0366
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Authorized Official
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Title or Position | OWNER
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Name | DR. DAVID D. WYSE
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Credential | DDS
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Telephone | 309-663-6393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 060001892
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License Number State | IL
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