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General NPI Number Information
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NPI Number | 1598805590
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Entity Type | Individual
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Provider Name | DUSTIN ALAN WYLAM D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 09/14/2007
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Provider Practice Location Address
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Address Line | 655 7TH ST
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City | ROBINS AFB
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State | GA
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Zip | 31098-2227
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Country | US
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Telephone | 503-309-4605
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Fax |
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Provider Business Mailing Address
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Address Line | 3500 HARBISON DR APT 536
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City | VACAVILLE
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State | CA
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Zip | 95687-3917
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Country | US
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Telephone | 503-309-4605
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D8863
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License Number State | OR
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