Provider Demographics
NPI:1891311379
Name:WEAVER, JONATHAN FREDERICK (DMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:FREDERICK
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 1:302 MEADOWCREST DR
Mailing Address - Street 2:
Mailing Address - City:TRUCKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9481
Mailing Address - Country:US
Mailing Address - Phone:570-574-5813
Mailing Address - Fax:
Practice Address - Street 1:HEADQUARTERS UNITED STATES ARMY DENTAL HEALTH ACTIVITY
Practice Address - Street 2:4323 HILL STREET
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:29207-6022
Practice Address - Country:US
Practice Address - Phone:803-751-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist