Provider Demographics
NPI:1093801433
Name:WYETH, ELIZABETH (LDH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WYETH
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7486 FOX HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8393
Mailing Address - Country:US
Mailing Address - Phone:317-840-3997
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN ST # E116
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5186
Practice Address - Country:US
Practice Address - Phone:317-278-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13005033A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist