Healthcare Provider Details

I. General information

NPI: 1952402158
Provider Name (Legal Business Name): DAVID D. WYNN, D.D.S. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6495 ALVARADO RD SUITE 102
SAN DIEGO CA
92120-5004
US

IV. Provider business mailing address

6495 ALVARADO RD SUITE 102
SAN DIEGO CA
92120-5004
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-8870
  • Fax:
Mailing address:
  • Phone: 619-287-8870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD22569-01
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID D WYNN
Title or Position: OWNER
Credential: D.D.S.
Phone: 619-287-8870