Healthcare Provider Details

I. General information

NPI: 1053119735
Provider Name (Legal Business Name): ISABELLA REESE AUGUSTINE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 W CENTER ST
MIDVALE UT
84047-7364
US

IV. Provider business mailing address

49 W CENTER ST
MIDVALE UT
84047-7364
US

V. Phone/Fax

Practice location:
  • Phone: 385-887-9002
  • Fax:
Mailing address:
  • Phone: 385-887-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14292042-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: