Healthcare Provider Details

I. General information

NPI: 1114016250
Provider Name (Legal Business Name): MARK C. WESTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W LOGAN RD
GARDEN CITY UT
84028-7754
US

IV. Provider business mailing address

517 W 100 N STE 210
PROVIDENCE UT
84332-9826
US

V. Phone/Fax

Practice location:
  • Phone: 435-946-3660
  • Fax: 435-946-8215
Mailing address:
  • Phone: 435-755-6061
  • Fax: 435-994-8362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-5360
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12373907-9921
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-5360
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number956
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12373907-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: