Provider Demographics
NPI:1396094447
Name:WEAVER, LAURA MILLES (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:MILLES
Last Name:WEAVER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:MILLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6236 JAMISON CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5101
Mailing Address - Country:US
Mailing Address - Phone:904-616-6982
Mailing Address - Fax:
Practice Address - Street 1:223 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4301
Practice Address - Country:US
Practice Address - Phone:904-356-0072
Practice Address - Fax:904-356-2338
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN197461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice