Provider Demographics
NPI:1417211350
Name:WEGENER, JEFFREY DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:WEGENER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 N 200 E STE 200
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7565
Mailing Address - Country:US
Mailing Address - Phone:435-753-4400
Mailing Address - Fax:435-753-5599
Practice Address - Street 1:1451 N 200 E STE 200
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7565
Practice Address - Country:US
Practice Address - Phone:435-753-4400
Practice Address - Fax:435-753-5599
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8703919-9922122300000X
MT4140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist