Provider Demographics
NPI:1043566433
Name:WYNN, TAMRA RAE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:RAE
Last Name:WYNN
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1314
Mailing Address - Country:US
Mailing Address - Phone:781-581-3892
Mailing Address - Fax:781-581-9583
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-581-3892
Practice Address - Fax:781-581-9583
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH87919124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist