Provider Demographics
NPI:1821472325
Name:STANDISH, ELIZABETH (DDS, MSD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:STANDISH
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 KINGSWOOD RD S
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4671
Mailing Address - Country:US
Mailing Address - Phone:409-370-0570
Mailing Address - Fax:
Practice Address - Street 1:3743 LANDMARK DR STE 300
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6656
Practice Address - Country:US
Practice Address - Phone:765-340-7790
Practice Address - Fax:765-680-0303
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012992A122300000X, 1223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300029327AMedicaid