Provider Demographics
NPI:1548289002
Name:WEISENBERG, MARK JEFFREY (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:WEISENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5679 PORTAGE STREET
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-4134
Mailing Address - Country:US
Mailing Address - Phone:714-779-6332
Mailing Address - Fax:
Practice Address - Street 1:5679 PORTAGE ST
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-3743
Practice Address - Country:US
Practice Address - Phone:714-779-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253061223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics