Healthcare Provider Details

I. General information

NPI: 1265446561
Provider Name (Legal Business Name): TODD E WYNKOOP DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 LAKE RIDGE DR STE C
WOODBRIDGE VA
22192-7501
US

IV. Provider business mailing address

12510 LAKE RIDGE DR STE C
WOODBRIDGE VA
22192-7501
US

V. Phone/Fax

Practice location:
  • Phone: 703-494-8624
  • Fax: 703-497-1258
Mailing address:
  • Phone: 703-494-8624
  • Fax: 703-497-1258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401007464
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: