Provider Demographics
NPI:1063424638
Name:WYMAN, BRUCE S (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:S
Last Name:WYMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 ROLLING ROAD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1512
Mailing Address - Country:US
Mailing Address - Phone:703-569-4040
Mailing Address - Fax:703-569-7334
Practice Address - Street 1:6116 ROLLING ROAD
Practice Address - Street 2:SUITE 312
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1512
Practice Address - Country:US
Practice Address - Phone:703-569-4040
Practice Address - Fax:703-569-7334
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049731223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics