Provider Demographics
NPI:1982229985
Name:KOLIN E. WEAVER, DDS, MS, INC.
Entity Type:Organization
Organization Name:KOLIN E. WEAVER, DDS, MS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KOLIN
Authorized Official - Middle Name:EMRYS
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-972-5445
Mailing Address - Street 1:2316 RED WOLF BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6360
Mailing Address - Country:US
Mailing Address - Phone:870-972-5445
Mailing Address - Fax:
Practice Address - Street 1:2316 RED WOLF BLVD STE C
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6360
Practice Address - Country:US
Practice Address - Phone:870-972-5445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty