Provider Demographics
NPI:1609181916
Name:WEAVER, ROBERT VINCENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:VINCENT
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 HARTLEY RD
Mailing Address - Street 2:SUITE #120
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257
Mailing Address - Country:US
Mailing Address - Phone:904-264-5437
Mailing Address - Fax:904-485-8417
Practice Address - Street 1:112 BARTRAM OAKS WALK
Practice Address - Street 2:SUITE #203
Practice Address - City:ST. JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-264-5437
Practice Address - Fax:904-485-8417
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18975122300000X
FL189751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist