Active NPI
Mark Wiatt, DDS
- Dentist
- T Or C, NM
National Provider Identifier
1801889209
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DD-2602
- Practice address
- 1960 N Date St
T Or C, NM 87901-3701 - Phone
- (505) 267-3088
- Fax
- (505) 267-1747
- NPI assigned
- Aug 31, 2005
- 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 | DD-2602 | NM | Primary |
Addresses
Primary practice location
1960 N Date St
T Or C, NM 87901-3701
Mailing address
255 Hwy 187
PO Box 370
Hatch, NM 87937-0730
Phone (505) 267-3088
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 92422071 | Medicaid | NM |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NM
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150604000206 | NM | Order and Referring Only - Dentist | 7315268232 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DD-2602 | NM | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1125446400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1197936000000",
"number": "1801889209",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "255 HWY 187",
"address_2": "PO BOX 370",
"city": "HATCH",
"state": "NM",
"postal_code": "879370730",
"telephone_number": "505-267-3088",
"fax_number": "505-267-1747"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1960 N DATE ST",
"city": "T OR C",
"state": "NM",
"postal_code": "879013701",
"telephone_number": "505-267-3088",
"fax_number": "505-267-1747"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIATT",
"first_name": "MARK",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-08-31",
"last_updated": "2007-12-18",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NM",
"license": "DD-2602",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "92422071",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in T Or C, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.