Provider Demographics
NPI:1720196298
Name:MARK, WESLEY RAY (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:RAY
Last Name:MARK
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3085
Mailing Address - Country:US
Mailing Address - Phone:574-266-6107
Mailing Address - Fax:
Practice Address - Street 1:320 W BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3085
Practice Address - Country:US
Practice Address - Phone:574-266-6107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008923122300000X
MND10235122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist