Provider Demographics
NPI:1205949294
Name:WEAVER, DANIEL ALLISON (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ALLISON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 E STARR AVE
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4325
Mailing Address - Country:US
Mailing Address - Phone:936-564-9320
Mailing Address - Fax:936-564-6779
Practice Address - Street 1:1520 E STARR AVE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4325
Practice Address - Country:US
Practice Address - Phone:936-564-9320
Practice Address - Fax:936-564-6779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104591223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU14754Medicare UPIN
TXD10459Medicare ID - Type Unspecified