=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780901355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYATT DENTAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2010
-----------------------------------------------------
Last Update Date | 04/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5037 VETERANS MEMORIAL BLVD STE 3E
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-5136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-885-1039
-----------------------------------------------------
Fax | 504-885-2028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5037 VETERANS MEMORIAL BLVD STE 3E
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-885-1039
-----------------------------------------------------
Fax | 504-885-2028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. LISA WYATT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 504-885-1039
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------