Healthcare Provider Details

I. General information

NPI: 1235119280
Provider Name (Legal Business Name): ROSA D WYNN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12948 VILLAGE DR STE B
SARATOGA CA
95070-4157
US

IV. Provider business mailing address

12948 VILLAGE DR STE B
SARATOGA CA
95070-4157
US

V. Phone/Fax

Practice location:
  • Phone: 408-257-1272
  • Fax: 408-257-2147
Mailing address:
  • Phone: 408-257-1272
  • Fax: 408-257-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: