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General NPI Number Information
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NPI Number | 1932249299
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Entity Type | Organization
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Legal Business Name | DUSTIN B. WISE, M.D., P.C.
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1888 W 800 N
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-4097
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Country | US
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Telephone | 801-492-7851
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Fax | 801-492-7883
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Provider Business Mailing Address
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Address Line | 1888 W 800 N
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-4097
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Country | US
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Telephone | 801-492-7851
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Fax | 801-492-7883
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Authorized Official
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Title or Position | OWNER
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Name | DUSTIN B. WISE
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Credential | M.D.
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Telephone | 801-492-7851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 5247966-1205
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License Number State | UT
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