Provider Demographics
NPI:1659690352
Name:SORENSEN, MARK WELDON (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WELDON
Last Name:SORENSEN
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 1:8101 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8454
Mailing Address - Country:US
Mailing Address - Phone:928-775-2545
Mailing Address - Fax:928-775-2535
Practice Address - Street 1:8101 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8454
Practice Address - Country:US
Practice Address - Phone:928-775-2545
Practice Address - Fax:928-775-2535
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0089001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ917971Medicaid