Provider Demographics
NPI:1659915437
Name:WEIMER DENTAL PLLC
Entity Type:Organization
Organization Name:WEIMER DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:JON
Authorized Official - Last Name:WEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-805-0389
Mailing Address - Street 1:186 MOUNTAIN VISTA AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9168
Mailing Address - Country:US
Mailing Address - Phone:541-805-0389
Mailing Address - Fax:
Practice Address - Street 1:8336 W NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7132
Practice Address - Country:US
Practice Address - Phone:208-375-4544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental