Provider Demographics
NPI:1689795718
Name:SOE L. WYNN, DMD, INC.
Entity type:Organization
Organization Name:SOE L. WYNN, DMD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOE
Authorized Official - Middle Name:LWIN
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:209-238-9444
Mailing Address - Street 1:2030 COFFEE ROAD
Mailing Address - Street 2:SUITE C-4
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8425
Mailing Address - Country:US
Mailing Address - Phone:209-238-9444
Mailing Address - Fax:209-238-9446
Practice Address - Street 1:2030 COFFEE RD
Practice Address - Street 2:SUITE C-4
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2413
Practice Address - Country:US
Practice Address - Phone:209-238-9444
Practice Address - Fax:209-238-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty