Provider Demographics
NPI:1174199434
Name:WYNN DENTAL CORPORATION
Entity Type:Organization
Organization Name:WYNN DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:CELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-795-2420
Mailing Address - Street 1:6615 W HAPPY VALLEY RD STE 103104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2608
Mailing Address - Country:US
Mailing Address - Phone:623-267-8088
Mailing Address - Fax:
Practice Address - Street 1:6615 W HAPPY VALLEY RD STE 103104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-2608
Practice Address - Country:US
Practice Address - Phone:623-267-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYNN DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty