Provider Demographics
NPI:1841996717
Name:WYCOFF, STEFANIE (RDH, OMT)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:WYCOFF
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 FAY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-2204
Mailing Address - Country:US
Mailing Address - Phone:719-648-8844
Mailing Address - Fax:
Practice Address - Street 1:451 14TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1609
Practice Address - Country:US
Practice Address - Phone:719-346-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10639124Q00000X
CO905098124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist