Provider Demographics
NPI:1679620355
Name:WEAVER I I I, WREX ALGER (DDS)
Entity Type:Individual
Prefix:DR
First Name:WREX
Middle Name:ALGER
Last Name:WEAVER I I I
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 1:1311 WOODLAWN PARK DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2767
Mailing Address - Country:US
Mailing Address - Phone:810-767-2945
Mailing Address - Fax:810-767-3032
Practice Address - Street 1:2740 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4534
Practice Address - Country:US
Practice Address - Phone:810-767-2945
Practice Address - Fax:810-767-3032
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBW31239521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851581Medicaid