Provider Demographics
NPI:1538178884
Name:WIEST, GARY BRENT (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:BRENT
Last Name:WIEST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:BRENT
Other - Last Name:WIEST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:168 W 800 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1624
Mailing Address - Country:US
Mailing Address - Phone:801-374-8205
Mailing Address - Fax:801-374-8215
Practice Address - Street 1:168 W 800 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1624
Practice Address - Country:US
Practice Address - Phone:801-374-8205
Practice Address - Fax:801-374-8215
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142629122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist