Healthcare Provider Details

I. General information

NPI: 1548289002
Provider Name (Legal Business Name): MARK JEFFREY WEISENBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5679 PORTAGE ST
YORBA LINDA CA
92887-3743
US

IV. Provider business mailing address

5679 PORTAGE STREET
YORBA LINDA CA
92887-4134
US

V. Phone/Fax

Practice location:
  • Phone: 714-779-6332
  • Fax:
Mailing address:
  • Phone: 714-779-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number25306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: