Provider Demographics
NPI:1164914222
Name:WYNNE, MARIAN ALEXANDRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:ALEXANDRA
Last Name:WYNNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 W H SMITH BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5278
Mailing Address - Country:US
Mailing Address - Phone:252-321-2070
Mailing Address - Fax:252-321-6984
Practice Address - Street 1:1025 W H SMITH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5278
Practice Address - Country:US
Practice Address - Phone:252-321-2070
Practice Address - Fax:252-321-6984
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice