Provider Demographics
NPI:1205135522
Name:ODELL, ELIZABETH PHAM (DMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PHAM
Last Name:ODELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2778 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526
Mailing Address - Country:US
Mailing Address - Phone:681-233-4025
Mailing Address - Fax:681-233-4039
Practice Address - Street 1:2778 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:681-233-4025
Practice Address - Fax:681-233-4039
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV40421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program