Provider Demographics
NPI:1508236258
Name:GARY E. WEBER, DDS, PC
Entity Type:Organization
Organization Name:GARY E. WEBER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-825-1121
Mailing Address - Street 1:1910 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2834
Mailing Address - Country:US
Mailing Address - Phone:765-825-1121
Mailing Address - Fax:765-827-1197
Practice Address - Street 1:1910 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2834
Practice Address - Country:US
Practice Address - Phone:765-825-1121
Practice Address - Fax:765-827-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007534A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250410AMedicaid