Provider Demographics
NPI:1508933946
Name:WEAVER, JOHN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
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 1:3641 ENSIGN RD NE STE 6A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5046
Mailing Address - Country:US
Mailing Address - Phone:360-915-6321
Mailing Address - Fax:360-489-1748
Practice Address - Street 1:3641 ENSIGN RD NE STE 6A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5046
Practice Address - Country:US
Practice Address - Phone:360-915-6321
Practice Address - Fax:360-489-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000051111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0035126OtherL & I PROVIDER NUMBER
WA000843827OtherUNITED CONCORDIA PROVIDER
WA5550603Medicaid