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NPI Code Detail

MEDICARE: AMY M WYATT DMD

MEDICARE: AMY M 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
1122300000XDentistIL

General Provider Information

NPI Number : 1396755856
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY M WYATT DMD
Provider Business Mailing Address
First Line : 285 OWL CREEK RD
Second Line :
City : MURPHYSBORO
State : IL
Zip : 62966-5868
Country : US
Telephone Number : 618-303-8086
Fax Number :
Provider Business Practice Location Address
First Line : 101 S WALL ST
Second Line :
City : CARBONDALE
State : IL
Zip : 62901-3021
Country : US
Telephone Number : 618-529-2621
Fax Number : 618-549-1288
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/08/2006
Last Update Date : 07/08/2007

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