Healthcare Provider Details

I. General information

NPI: 1093801433
Provider Name (Legal Business Name): ELIZABETH WYETH LDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/24/2021
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST # E116
INDIANAPOLIS IN
46202-5186
US

IV. Provider business mailing address

7486 FOX HOLLOW CT
ZIONSVILLE IN
46077-8393
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-8177
  • Fax:
Mailing address:
  • Phone: 317-840-3997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13005033A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: