Provider Demographics
NPI:1326128521
Name:WEAVER, JOHN MARK (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
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 1:2000 N GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761
Mailing Address - Country:US
Mailing Address - Phone:432-362-2202
Mailing Address - Fax:432-362-0690
Practice Address - Street 1:2000 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761
Practice Address - Country:US
Practice Address - Phone:432-362-2202
Practice Address - Fax:432-362-0690
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist