Provider Demographics
NPI:1629310446
Name:AUGUSTINE, STEPHANIE JO (RDH)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JO
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-3905
Mailing Address - Country:US
Mailing Address - Phone:620-615-5577
Mailing Address - Fax:620-615-5752
Practice Address - Street 1:330 CHARLES ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-3905
Practice Address - Country:US
Practice Address - Phone:620-615-5577
Practice Address - Fax:620-615-5752
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10047124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist