MEDICARE: DR. MARK C. WESTON DDS

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	1223G0001X	General Practice Dentistry	D-5360	ID
2	122300000X	Dentist	D-5360	ID
3	1223G0001X	General Practice Dentistry	956	WY
4	1223G0001X	General Practice Dentistry	12373907-9921	UT
5	122300000X	Dentist	12373907-9921	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114016250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK C. WESTON DDS

Provider Business Mailing Address
First Line	:	517 W 100 N STE 210
Second Line	:
City	:	PROVIDENCE
State	:	UT
Zip	:	84332-9826
Country	:	US
Telephone Number	:	435-755-6061
Fax Number	:	435-994-8362

Provider Business Practice Location Address
First Line	:	325 W LOGAN RD
Second Line	:
City	:	GARDEN CITY
State	:	UT
Zip	:	84028-7754
Country	:	US
Telephone Number	:	435-946-3660
Fax Number	:	435-946-8215

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/28/2022

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Directions to “ DR. MARK C. WESTON DDS” Practice Location

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