Provider Demographics
NPI:1760115729
Name:LE, ELIZABETH (DMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9612 PHIPPS LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3404
Mailing Address - Country:US
Mailing Address - Phone:561-713-3285
Mailing Address - Fax:
Practice Address - Street 1:516 MARY ESTHER CTO NW STE 2
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4025
Practice Address - Country:US
Practice Address - Phone:850-659-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26837122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist