Provider Demographics
NPI:1760524300
Name:WYNKOOP, JUDSON RUDOLPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:RUDOLPH
Last Name:WYNKOOP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2930
Mailing Address - Country:US
Mailing Address - Phone:614-252-0936
Mailing Address - Fax:614-252-7260
Practice Address - Street 1:1583 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2930
Practice Address - Country:US
Practice Address - Phone:614-252-0936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-7000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0533266Medicaid