Basic Information
Provider Information
NPI: 1003003054
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WYBLE
FirstName: JOHN
MiddleName: F
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 117 FOX PLAN DR
Address2: #203
City: MONROEVILLE
State: PA
PostalCode: 15146
CountryCode: US
TelephoneNumber: 4123724243
FaxNumber:  
Practice Location
Address1: 117 FOX PLAN DR
Address2: #203
City: MONROEVILLE
State: PA
PostalCode: 15146
CountryCode: US
TelephoneNumber: 4123724243
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/03/2007
LastUpdateDate: 03/01/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001XDS015819LPAY Dental ProvidersDentistGeneral Practice

No ID Information.


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