Provider Demographics
NPI:1235119280
Name:WYNN, ROSA D (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSA
Middle Name:D
Last Name:WYNN
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 1:12948 VILLAGE DR
Mailing Address - Street 2:STE B
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-4157
Mailing Address - Country:US
Mailing Address - Phone:408-257-1272
Mailing Address - Fax:408-257-2147
Practice Address - Street 1:12948 VILLAGE DR
Practice Address - Street 2:STE B
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-4157
Practice Address - Country:US
Practice Address - Phone:408-257-1272
Practice Address - Fax:408-257-2147
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA442311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice