Active NPI
Brandon R Wyatt, DDS
- Dentist
- Clyde, NC
National Provider Identifier
1104084193
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 8590
- Practice address
- 103 Haywood Park Dr
Clyde, NC 28721-4405 - Phone
- (828) 627-1050
- Fax
- (828) 627-1056
- NPI assigned
- May 27, 2008
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 8590 | NC | Primary |
Addresses
Primary practice location
103 Haywood Park Dr
Clyde, NC 28721-4405
Mailing address
103 Haywood Park Dr
Clyde, NC 28721-4405
Phone (828) 627-1050
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 1, 2022 through Jan 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 8590 | NC | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1211846400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1312848000000",
"number": "1104084193",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "103 HAYWOOD PARK DR",
"city": "CLYDE",
"state": "NC",
"postal_code": "287214405",
"telephone_number": "828-627-1050",
"fax_number": "828-627-1056"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "103 HAYWOOD PARK DR",
"city": "CLYDE",
"state": "NC",
"postal_code": "287214405",
"telephone_number": "828-627-1050",
"fax_number": "828-627-1056"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WYATT",
"first_name": "BRANDON",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2008-05-27",
"last_updated": "2011-08-09",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NC",
"license": "8590",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Clyde, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 9, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.