Individual
DUSTIN BRYANT WISE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1888 W 800 N, PLEASANT GROVE, UT 84062-4097
(801) 492-7851
(801) 492-7883
Mailing address
1888 W 800 N, PLEASANT GROVE, UT 84062
(801) 492-7851
(801) 492-7883
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
52479661205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
107017722102
IHC HEALTH PLANS
UT
Enumeration date
05/04/2006
Last updated
09/09/2021
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