Provider Demographics
NPI:1548427776
Name:MICHAEL D WEAVER DDS PC
Entity Type:Organization
Organization Name:MICHAEL D WEAVER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DON
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-657-3117
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:LONE GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:73443-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16931 US HWY 70
Practice Address - Street 2:
Practice Address - City:LONE GROVE
Practice Address - State:OK
Practice Address - Zip Code:73443-1270
Practice Address - Country:US
Practice Address - Phone:580-657-3117
Practice Address - Fax:580-657-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty