Provider Demographics
NPI:1003917204
Name:WEAVER, RUSSELL EVERETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:EVERETTE
Last Name:WEAVER
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 1:8035 MADISON AVE
Mailing Address - Street 2:SUITE E-4
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7949
Mailing Address - Country:US
Mailing Address - Phone:916-965-1200
Mailing Address - Fax:916-965-3524
Practice Address - Street 1:8035 MADISON AVE
Practice Address - Street 2:SUITE E-4
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7949
Practice Address - Country:US
Practice Address - Phone:916-965-1200
Practice Address - Fax:916-965-3524
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282561223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics