Provider Demographics
NPI:1578944179
Name:WEAVER, ANDREW T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:T
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 1:9555 N GRACE LAKE RD SE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7383
Mailing Address - Country:US
Mailing Address - Phone:218-368-3331
Mailing Address - Fax:
Practice Address - Street 1:1900 DIVISION ST W UNIT 2
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6397
Practice Address - Country:US
Practice Address - Phone:218-333-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice