Provider Demographics
NPI:1427222405
Name:WYMAN, KENNETH W II
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:WYMAN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80299
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-0299
Mailing Address - Country:US
Mailing Address - Phone:907-457-8739
Mailing Address - Fax:907-456-7510
Practice Address - Street 1:1225 WELL ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-2836
Practice Address - Country:US
Practice Address - Phone:907-456-6850
Practice Address - Fax:907-456-7510
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKUNKNOWN122300000X, 1223P0221X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry