Provider Demographics
NPI:1578884235
Name:WEAVER, KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0248
Mailing Address - Country:US
Mailing Address - Phone:208-785-2255
Mailing Address - Fax:208-785-2275
Practice Address - Street 1:310 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1710
Practice Address - Country:US
Practice Address - Phone:208-785-2255
Practice Address - Fax:208-785-2275
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist