MEDICARE: DR. WYATT TRENT WOOD D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6450	AZ

General Provider Information

NPI Number	:	1952463259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WYATT TRENT WOOD D.D.S.

Provider Business Mailing Address
First Line	:	41930 N. VENTURE DRIVE SUITE 150
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-0458
Country	:	US
Telephone Number	:	623-792-7323
Fax Number	:	623-444-4895

Provider Business Practice Location Address
First Line	:	41930 N. VENTURE DRIVE SUITE 150
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-0458
Country	:	US
Telephone Number	:	623-792-7323
Fax Number	:	623-444-4895

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/23/2019

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