Individual
MARK WIATT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1960 N DATE ST, T OR C, NM 87901-3701
(505) 267-3088
(505) 267-1747
Mailing address
255 HWY 187, PO BOX 370, HATCH, NM 87937-0730
(505) 267-3088
(505) 267-1747
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DD-2602
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
92422071
—
NM
Enumeration date
08/31/2005
Last updated
12/18/2007
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