Provider Demographics
NPI:1649311440
Name:WIESEN, MARK JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:WIESEN
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 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 2400
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-989-0550
Mailing Address - Fax:415-989-0554
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:SUITE 2400
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-989-0550
Practice Address - Fax:415-989-0554
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics