Provider Demographics
NPI:1962160358
Name:WILLIAM T WYNNE, DDS, PLLC
Entity type:Organization
Organization Name:WILLIAM T WYNNE, DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-778-2477
Mailing Address - Street 1:100 STADIUM OAKS DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8961
Mailing Address - Country:US
Mailing Address - Phone:336-778-2477
Mailing Address - Fax:336-778-2437
Practice Address - Street 1:100 STADIUM OAKS DR STE A
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8961
Practice Address - Country:US
Practice Address - Phone:336-793-0577
Practice Address - Fax:336-778-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-02
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518379601OtherTYPE 1 NPI