=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841996717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEFANIE WYCOFF RDH, OMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2023
-----------------------------------------------------
Last Update Date | 02/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 14TH ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80807-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-346-4681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1890 FAY ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80807-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-648-8844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 10639
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 905098
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------