Provider Demographics
NPI:1376769315
Name:MARY ELLEN WYNN, D.D.S.,LLC
Entity Type:Organization
Organization Name:MARY ELLEN WYNN, D.D.S.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-922-4221
Mailing Address - Street 1:3650 MUDDY CREEK ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2044
Mailing Address - Country:US
Mailing Address - Phone:513-922-4221
Mailing Address - Fax:513-922-5634
Practice Address - Street 1:3650 MUDDY CREEK ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2044
Practice Address - Country:US
Practice Address - Phone:513-922-4221
Practice Address - Fax:513-922-5634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH155961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty