Provider Demographics
NPI:1932249299
Name:DUSTIN B. WISE, M.D., P.C.
Entity type:Organization
Organization Name:DUSTIN B. WISE, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-492-7851
Mailing Address - Street 1:1888 W 800 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4097
Mailing Address - Country:US
Mailing Address - Phone:801-492-7851
Mailing Address - Fax:801-492-7883
Practice Address - Street 1:1888 W 800 N
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4097
Practice Address - Country:US
Practice Address - Phone:801-492-7851
Practice Address - Fax:801-492-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5247966-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT516086578002Medicaid