Ellen Renee Wyant, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2901015477 Issued in MI

Practice address

104 Grant St
Niles, MI 49120-2201

Phone

(269) 683-1077

Fax

(269) 684-5305

NPI assigned

Dec 6, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Mrs. Ellen Renee Petro Other name

Medicare fee-for-service enrollment

Enrolled in MI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1425340800000",
    "number": "1144389396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 GRANT ST",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491202201",
            "telephone_number": "269-683-1077",
            "fax_number": "269-684-5305"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 GRANT ST",
            "city": "NILES",
            "state": "MI",
            "postal_code": "491202201",
            "telephone_number": "269-683-1077",
            "fax_number": "269-684-5305"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WYANT",
        "first_name": "ELLEN",
        "middle_name": "RENEE",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-12-06",
        "last_updated": "2015-03-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901015477",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4498490",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "ELLEN",
            "last_name": "PETRO",
            "middle_name": "RENEE",
            "prefix": "MRS.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Angelica Williams, LLPC
• Donnette M Williams
• Joshua Wingate
• Alexius Lauren Wlodarski
• Jaime Denise Wright, OTR
• Vicki L Yarbro
• Ashley Yoder
• John Mourad Zakhary, MD
• Periza Zaninovic, D.D.S.
• Elizabeth Zech, NP

• General Practice Dentistry in Niles, MI
• Providers in Niles, MI by specialty
• General Practice Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.