Provider Demographics
NPI:1437435781
Name:AWL DENTISTRY PC
Entity Type:Organization
Organization Name:AWL DENTISTRY PC
Other - Org Name:ADVANTAGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-284-0054
Mailing Address - Street 1:3974 BELL CT
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-1411
Mailing Address - Country:US
Mailing Address - Phone:208-284-0054
Mailing Address - Fax:
Practice Address - Street 1:170 S CREASY LN STE 1730
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0759
Practice Address - Country:US
Practice Address - Phone:765-913-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011732A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty