=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720293913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYDIA C. WYATT, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9500 W FLAMINGO RD SUITE 200
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-220-9555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9500 W FLAMINGO RD SUITE 200
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-220-9555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LYDIA CLAIRE WYATT
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 702-220-9555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4340
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------