Healthcare Provider Details

I. General information

NPI: 1841502879
Provider Name (Legal Business Name): WYNNEWOOD DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 S HAMPTON RD SUITE 103
DALLAS TX
75232-1066
US

IV. Provider business mailing address

4650 S HAMPTON RD SUITE 103
DALLAS TX
75232-1066
US

V. Phone/Fax

Practice location:
  • Phone: 214-943-1311
  • Fax: 214-943-5125
Mailing address:
  • Phone: 214-943-1311
  • Fax: 214-943-5125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14702
License Number StateTX

VIII. Authorized Official

Name: DR. SHIRLEY ANN TAULTON
Title or Position: OWNER
Credential: DDS
Phone: 214-943-1311