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General NPI Number Information
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NPI Number | 1588049233
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Entity Type | Individual
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Provider Name | MICAH WEISENBERG DDS
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Gender | Male
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Dates
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Enumeration Date | 07/23/2015
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 1144 E FORT UNION BLVD
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City | MIDVALE
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State | UT
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Zip | 84047
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Country | US
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Telephone | 801-566-3118
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Fax |
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Provider Business Mailing Address
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Address Line | 1235 E WILMINGTON AVE APT 317
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-4265
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Country | US
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Telephone | 301-661-1459
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 15995
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10757585-9922
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License Number State | UT
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