Provider Demographics
NPI:1083787170
Name:WEBER, MARY KATHERINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHERINE
Last Name:WEBER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2885
Mailing Address - Country:US
Mailing Address - Phone:217-345-2176
Mailing Address - Fax:217-345-2195
Practice Address - Street 1:1063 10TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2885
Practice Address - Country:US
Practice Address - Phone:217-345-2176
Practice Address - Fax:217-345-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19243121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201122OtherAGA NUMBER
IL1924312OtherLISENSE NUMBER