Provider Demographics
NPI:1144389396
Name:WYANT, ELLEN RENEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:RENEE
Last Name:WYANT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:RENEE
Other - Last Name:PETRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:104 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2201
Mailing Address - Country:US
Mailing Address - Phone:269-683-1077
Mailing Address - Fax:269-684-5305
Practice Address - Street 1:104 GRANT ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2201
Practice Address - Country:US
Practice Address - Phone:269-683-1077
Practice Address - Fax:269-684-5305
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010154771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4498490Medicaid