Provider Demographics
NPI:1508397977
Name:WYNN, SHARON (CDA, RDH)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:CDA, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3119
Mailing Address - Country:US
Mailing Address - Phone:970-564-4764
Mailing Address - Fax:970-565-0647
Practice Address - Street 1:106 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3119
Practice Address - Country:US
Practice Address - Phone:970-564-4764
Practice Address - Fax:970-565-0647
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024655124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODH.002024655OtherCOLORADO DENTAL HYGIENE LICENSE
CO846000786OtherMONTEZUMA COUNTY PUBLIC HEALTH DEPARTMENT