Provider Demographics
NPI:1124757554
Name:CROWELL, WYATT ALLEN (DDS)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:ALLEN
Last Name:CROWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 BISSONNET ST APT 3143
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-1365
Mailing Address - Country:US
Mailing Address - Phone:614-557-8483
Mailing Address - Fax:
Practice Address - Street 1:9305 MARKET SQUARE DR
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5294
Practice Address - Country:US
Practice Address - Phone:330-422-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX385051223G0001X
OH30.0272441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice