Provider Demographics
NPI:1396828505
Name:WEAVER, PHILLIPS S (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIPS
Middle Name:S
Last Name:WEAVER
Suffix:
Gender:M
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:PO BOX 654
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568
Mailing Address - Country:US
Mailing Address - Phone:228-762-5561
Mailing Address - Fax:228-762-0313
Practice Address - Street 1:716 WATTS AVENUE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS155773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00062943Medicaid