Provider Demographics
NPI:1316011307
Name:WEBER, WALTER E (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:E
Last Name:WEBER
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 1:333 JACKSON
Mailing Address - Street 2:A SUITE
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:616-842-0822
Mailing Address - Fax:616-842-0955
Practice Address - Street 1:333 JACKSON
Practice Address - Street 2:A SUITE
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-842-0822
Practice Address - Fax:616-842-0955
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI119761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4047097Medicaid