Basic Information
| Provider Information | |||||||||
| NPI: | 1124086061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYAN | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY ROAD 7500 | ||||||||
| Address2: | USA DENTAC ALASKA FT WAINWRIGHT | ||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997037500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615530 | ||||||||
| FaxNumber: | 9073614859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY ROAD 7500 | ||||||||
| Address2: | USA DENTAC ALASKA FT WAINWRIGHT | ||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997037500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615530 | ||||||||
| FaxNumber: | 9073614859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 09/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DI 014669 | NJ | Y | Dental Providers | Dentist |
No ID Information.