Provider Demographics
NPI:1336210772
Name:WEBER, JACK MICHAEL (DMD MSD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:WEBER
Suffix:
Gender:M
Credentials:DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 COURT ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901
Mailing Address - Country:US
Mailing Address - Phone:607-723-1941
Mailing Address - Fax:607-723-1306
Practice Address - Street 1:78 COURT ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-723-1941
Practice Address - Fax:607-723-1306
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0286351223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54831BMedicare ID - Type Unspecified
U47335Medicare UPIN