Provider Demographics
NPI:1407085624
Name:WEAVER, ZANE MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:ZANE
Middle Name:MICHAEL
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 1:358 CHARLESTON DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6082
Mailing Address - Country:US
Mailing Address - Phone:580-657-3117
Mailing Address - Fax:590-657-8081
Practice Address - Street 1:16931 U.S. HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:LONE GROVE
Practice Address - State:OK
Practice Address - Zip Code:73443
Practice Address - Country:US
Practice Address - Phone:580-657-3117
Practice Address - Fax:580-657-8081
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist