Provider Demographics
NPI:1861511313
Name:VIGNERI, MARK S (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:VIGNERI
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5860 E 2ND ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-315-6008
Mailing Address - Fax:307-315-6010
Practice Address - Street 1:5860 E 2ND ST
Practice Address - Street 2:STE 200
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609
Practice Address - Country:US
Practice Address - Phone:307-315-6008
Practice Address - Fax:307-315-6010
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY880402625Medicare UPIN