Provider Demographics
NPI:1336264423
Name:WYSE, TODD SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:SAMUEL
Last Name:WYSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57250 ALPHA DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-7804
Mailing Address - Country:US
Mailing Address - Phone:574-875-3817
Mailing Address - Fax:574-875-3984
Practice Address - Street 1:57250 ALPHA DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7804
Practice Address - Country:US
Practice Address - Phone:574-875-3817
Practice Address - Fax:574-875-3984
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120088341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice