Basic Information
| Provider Information | |||||||||
| NPI: | 1114016250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 517 W 100 N STE 210 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843329826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 4359948362 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 W LOGAN RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840287754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359463660 | ||||||||
| FaxNumber: | 4359468215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D-5360 | ID | N | Dental Providers | Dentist | General Practice | 122300000X | D-5360 | ID | N | Dental Providers | Dentist | 1223G0001X | 956 | WY | N | Dental Providers | Dentist | General Practice | 1223G0001X | 12373907-9921 | UT | N | Dental Providers | Dentist | General Practice | 122300000X | 12373907-9921 | UT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 115359500 | 05 | WY | MEDICAID |