Healthcare Provider Details

I. General information

NPI: 1336264423
Provider Name (Legal Business Name): TODD SAMUEL WYSE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57250 ALPHA DR
GOSHEN IN
46528-7804
US

IV. Provider business mailing address

57250 ALPHA DR
GOSHEN IN
46528-7804
US

V. Phone/Fax

Practice location:
  • Phone: 574-875-3817
  • Fax: 574-875-3984
Mailing address:
  • Phone: 574-875-3817
  • Fax: 574-875-3984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12008834
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: