Provider Demographics
NPI:1710964838
Name:WYNN, MARY ELLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:WYNN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 MUDDY CREEK RD
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 RD
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-55961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice