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General NPI Number Information
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NPI Number | 1902794928
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Entity Type | Individual
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Provider Name | MARISSA WAGEHOFT DMD
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Gender | Female
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Dates
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Enumeration Date | 06/26/2025
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 176 SKYLINE DR
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City | KERSEY
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State | PA
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Zip | 15846-9146
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Country | US
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Telephone | 814-486-0909
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Fax |
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Provider Business Mailing Address
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Address Line | 712 VALLEY DR
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City | EAST ALTON
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State | IL
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Zip | 62024-1318
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS045212
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License Number State | PA
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