Provider Demographics
NPI:1902929169
Name:WISNER, MARCUS D (DMD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:D
Last Name:WISNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 S 1100 E STE 330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1274
Mailing Address - Country:US
Mailing Address - Phone:801-262-9785
Mailing Address - Fax:
Practice Address - Street 1:3920 S 1100 E STE 330
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1274
Practice Address - Country:US
Practice Address - Phone:801-262-9785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5079227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist