Healthcare Provider Details

I. General information

NPI: 1245359371
Provider Name (Legal Business Name): WILLIAM BERNARD WYNN IV D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE SUITE 1008
TULSA OK
74136-8378
US

IV. Provider business mailing address

6565 S YALE AVE SUITE 1008
TULSA OK
74136-8378
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-0737
  • Fax: 918-492-9439
Mailing address:
  • Phone: 918-492-0737
  • Fax: 918-492-9439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5447
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: