MEDICARE: DR. KENNETH ROBERT WYATT DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	012032	GA

General Provider Information

NPI Number	:	1295806461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ROBERT WYATT DMD

Provider Business Mailing Address
First Line	:	9020 CHAMPION CT
Second Line	:
City	:	BALL GROUND
State	:	GA
Zip	:	30107-7018
Country	:	US
Telephone Number	:	770-888-3072
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 ELM ST
Second Line	:	SUITE 200
City	:	CUMMING
State	:	GA
Zip	:	30040-8233
Country	:	US
Telephone Number	:	770-887-2915
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	06/11/2014

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