Provider Demographics
NPI:1669518577
Name:WEAVER, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2797 CAMPBELLTON RD SW
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-4455
Mailing Address - Country:US
Mailing Address - Phone:404-346-1120
Mailing Address - Fax:
Practice Address - Street 1:2797 CAMPBELLTON RD SW
Practice Address - Street 2:SUITE A-4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-4455
Practice Address - Country:US
Practice Address - Phone:404-346-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice