Provider Demographics
NPI:1780901355
Name:WYATT DENTAL GROUP, LLC
Entity type:Organization
Organization Name:WYATT DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-885-1039
Mailing Address - Street 1:5037 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:STE 3E
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006
Mailing Address - Country:US
Mailing Address - Phone:504-885-1039
Mailing Address - Fax:504-885-2028
Practice Address - Street 1:5037 VETERANS MEMORIAL BLVD
Practice Address - Street 2:STE 3E
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-5136
Practice Address - Country:US
Practice Address - Phone:504-885-1039
Practice Address - Fax:504-885-2028
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LISA WYATT, D.D.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty