MEDICARE: MARCUS D WISNER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5079227	UT

General Provider Information

NPI Number	:	1902929169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS D WISNER DMD

Provider Business Mailing Address
First Line	:	3920 S 1100 E STE 330
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1274
Country	:	US
Telephone Number	:	801-262-9785
Fax Number	:

Provider Business Practice Location Address
First Line	:	3920 S 1100 E STE 330
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1274
Country	:	US
Telephone Number	:	801-262-9785
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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