Provider Demographics
NPI:1134243470
Name:MAYWEATHER, GEORGE SHANNON (DDS)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:SHANNON
Last Name:MAYWEATHER
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 1:8013 LAGUNA BLVD # 1
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7920
Mailing Address - Country:US
Mailing Address - Phone:916-683-3015
Mailing Address - Fax:916-683-5150
Practice Address - Street 1:8013 LAGUNA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7920
Practice Address - Country:US
Practice Address - Phone:916-683-3015
Practice Address - Fax:916-683-5150
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404671223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20 -0752922OtherEIN