Provider Demographics
NPI:1164859344
Name:JOHN T WEAVER DMD PC
Entity Type:Organization
Organization Name:JOHN T WEAVER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:404-346-1120
Mailing Address - Street 1:2797 CAMPBELLTON RD SW
Mailing Address - Street 2:SUITE A4
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-4455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2797 CAMPBELLTON RD SW
Practice Address - Street 2:SUITE A4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-4455
Practice Address - Country:US
Practice Address - Phone:404-346-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000445871BMedicaid