Provider Demographics
NPI:1629451471
Name:WEAVER, DANTEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANTEL
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-4508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-4508
Practice Address - Country:US
Practice Address - Phone:952-471-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND137691223G0001X
TX322821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice