Provider Demographics
NPI:1720121023
Name:WYNN, JENNIFER DIANE (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:WYNN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:WYNN
Other - Last Name:KERNAGIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:5486 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2853
Mailing Address - Country:US
Mailing Address - Phone:813-571-5555
Mailing Address - Fax:813-571-5559
Practice Address - Street 1:5486 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-2853
Practice Address - Country:US
Practice Address - Phone:813-571-5555
Practice Address - Fax:813-571-5559
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice