Provider Demographics
NPI:1871722553
Name:WYATT, STANLEY J (DMD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:WYATT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2737
Mailing Address - Country:US
Mailing Address - Phone:859-252-5220
Mailing Address - Fax:859-252-0405
Practice Address - Street 1:1330 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2737
Practice Address - Country:US
Practice Address - Phone:859-252-5220
Practice Address - Fax:859-252-0405
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist