Provider Demographics
NPI:1407957947
Name:WEAVER, CLINTON E (DDS)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:E
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 1:1202 FARMERS LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6707
Mailing Address - Country:US
Mailing Address - Phone:707-526-7036
Mailing Address - Fax:707-526-4569
Practice Address - Street 1:1202 FARMERS LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-6707
Practice Address - Country:US
Practice Address - Phone:707-526-7036
Practice Address - Fax:707-526-4569
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282541223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics