Provider Demographics
NPI:1528272499
Name:BRUCE S. WYMAN DMD, PC
Entity type:Organization
Organization Name:BRUCE S. WYMAN DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-569-4040
Mailing Address - Street 1:6116 ROLLING RD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1521
Mailing Address - Country:US
Mailing Address - Phone:703-569-4040
Mailing Address - Fax:703-569-7334
Practice Address - Street 1:6116 ROLLING RD
Practice Address - Street 2:SUITE 312
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1521
Practice Address - Country:US
Practice Address - Phone:703-569-4040
Practice Address - Fax:703-569-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049731223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty