Provider Demographics
NPI:1750592713
Name:WEAVER, STEPHANIE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-1523
Mailing Address - Country:US
Mailing Address - Phone:337-478-3123
Mailing Address - Fax:337-478-3229
Practice Address - Street 1:715 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-1523
Practice Address - Country:US
Practice Address - Phone:337-478-3123
Practice Address - Fax:337-478-3229
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5170122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist