Provider Demographics
NPI:1598883746
Name:WEGZYN, MARK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WEGZYN
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 1:761 BROCHARDT BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-0935
Mailing Address - Country:US
Mailing Address - Phone:865-288-3940
Mailing Address - Fax:
Practice Address - Street 1:914 NEW HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-2729
Practice Address - Country:US
Practice Address - Phone:423-337-2034
Practice Address - Fax:423-337-2036
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI 0128591223G0001X
MI29010128591223G0001X
TN89121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice