Provider Demographics
NPI:1073987038
Name:LIZZIE O'DELL PLLC
Entity Type:Organization
Organization Name:LIZZIE O'DELL PLLC
Other - Org Name:CREATIVE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PHAM
Authorized Official - Last Name:O'DELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-538-1390
Mailing Address - Street 1:3520 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9479
Mailing Address - Country:US
Mailing Address - Phone:334-538-1390
Mailing Address - Fax:
Practice Address - Street 1:3520 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9479
Practice Address - Country:US
Practice Address - Phone:334-538-1390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty