Healthcare Provider Details

I. General information

NPI: 1629310446
Provider Name (Legal Business Name): STEPHANIE JO AUGUSTINE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CHARLES ST
HUTCHINSON KS
67501-3905
US

IV. Provider business mailing address

330 CHARLES ST
HUTCHINSON KS
67501-3905
US

V. Phone/Fax

Practice location:
  • Phone: 620-615-5577
  • Fax: 620-615-5752
Mailing address:
  • Phone: 620-615-5577
  • Fax: 620-615-5752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10047
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: