Provider Demographics
NPI:1174961312
Name:WYNNE, WILLIAM PEMBERTON DIXON (DDS)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:PEMBERTON DIXON
Last Name:WYNNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 WESTERN BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606
Mailing Address - Country:US
Mailing Address - Phone:919-851-3716
Mailing Address - Fax:919-851-8383
Practice Address - Street 1:5009 WESTERN BLVD.
Practice Address - Street 2:SUITE A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606
Practice Address - Country:US
Practice Address - Phone:919-851-3716
Practice Address - Fax:919-851-8383
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC#36301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice