Provider Demographics
NPI:1215167564
Name:WYSHAK, GEORGE HABEEB (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HABEEB
Last Name:WYSHAK
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6966 HARVEST RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3659
Mailing Address - Country:US
Mailing Address - Phone:303-530-1310
Mailing Address - Fax:303-530-2999
Practice Address - Street 1:6966 HARVEST RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3659
Practice Address - Country:US
Practice Address - Phone:303-530-1310
Practice Address - Fax:303-530-2999
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8811122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist