Provider Demographics
NPI:1366599391
Name:WYMAN, BRETT DAWSON (DDS)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:DAWSON
Last Name:WYMAN
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 1:1614 N BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2804
Mailing Address - Country:US
Mailing Address - Phone:417-862-9925
Mailing Address - Fax:417-862-4541
Practice Address - Street 1:1614 N BENTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2804
Practice Address - Country:US
Practice Address - Phone:417-862-9925
Practice Address - Fax:417-862-4541
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist