MEDICARE: DR. ROBERT BRYAN WYETH 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	122300000X	Dentist	10303	CO
2	1223G0001X	General Practice Dentistry	10303	CO

General Provider Information

NPI Number	:	1811145105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT BRYAN WYETH DMD

Provider Business Mailing Address
First Line	:	1634 YORK RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918
Country	:	US
Telephone Number	:	719-522-0800
Fax Number	:	719-522-0810

Provider Business Practice Location Address
First Line	:	1634 YORK RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918
Country	:	US
Telephone Number	:	719-522-0800
Fax Number	:	719-522-0810

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

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	06/02/2015

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