Provider Demographics
NPI:1114016250
Name:WESTON, MARK C (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:WESTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W 100 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9826
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:435-994-8362
Practice Address - Street 1:325 W LOGAN RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028-7754
Practice Address - Country:US
Practice Address - Phone:435-946-3660
Practice Address - Fax:435-946-8215
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-53601223G0001X, 122300000X
WY9561223G0001X
UT12373907-99211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115359500Medicaid