Provider Demographics
NPI:1134658818
Name:WEAVER, DAMONE J
Entity Type:Individual
Prefix:
First Name:DAMONE
Middle Name:J
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10920 BAYMEADOWS RD STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4571
Mailing Address - Country:US
Mailing Address - Phone:904-363-3559
Mailing Address - Fax:
Practice Address - Street 1:10920 BAYMEADOWS RD STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4571
Practice Address - Country:US
Practice Address - Phone:904-363-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist