Provider Demographics
NPI:1396958005
Name:WEITEKAMP, GARY LOUIS (DDS)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LOUIS
Last Name:WEITEKAMP
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 1:2407 ST ANDREWS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2170
Mailing Address - Country:US
Mailing Address - Phone:850-763-5021
Mailing Address - Fax:850-769-5025
Practice Address - Street 1:2407 ST ANDREWS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2170
Practice Address - Country:US
Practice Address - Phone:850-763-5021
Practice Address - Fax:850-769-5025
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0009503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
547422OtherUNITED CONCORDIA INS CO