Healthcare Provider Details

I. General information

NPI: 1598690596
Provider Name (Legal Business Name): STEPHANIE DAWN WAGNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 E SPLENDOR VIEW CIR
MIDVALE UT
84047-1329
US

IV. Provider business mailing address

539 E SPLENDOR VIEW CIR
MIDVALE UT
84047-1329
US

V. Phone/Fax

Practice location:
  • Phone: 509-760-9425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number14210289-9920
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: