Provider Demographics
NPI:1215006325
Name:WRIGHT, MARK WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 SHOUP AVE W
Mailing Address - Street 2:ST. A
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5042
Mailing Address - Country:US
Mailing Address - Phone:208-735-1345
Mailing Address - Fax:208-734-4630
Practice Address - Street 1:414 SHOUP AVE W
Practice Address - Street 2:ST. A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5042
Practice Address - Country:US
Practice Address - Phone:208-735-1345
Practice Address - Fax:208-734-4630
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice