Provider Demographics
NPI:1528740701
Name:WYNN, TIARA
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 ESPLANADE WAY APT 4305
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-3762
Mailing Address - Country:US
Mailing Address - Phone:706-401-8781
Mailing Address - Fax:
Practice Address - Street 1:3715 OLD BRADFORDVILLE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-1962
Practice Address - Country:US
Practice Address - Phone:850-391-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN285001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice