Healthcare Provider Details

I. General information

NPI: 1811945769
Provider Name (Legal Business Name): DUSTIN BRYANT WISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1888 W 800 N
PLEASANT GROVE UT
84062-4097
US

IV. Provider business mailing address

1888 W 800 N
PLEASANT GROVE UT
84062
US

V. Phone/Fax

Practice location:
  • Phone: 801-492-7851
  • Fax: 801-492-7883
Mailing address:
  • Phone: 801-492-7851
  • Fax: 801-492-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52479661205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: