Provider Demographics
NPI:1932448602
Name:WEAVER, COLE A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:COLE
Middle Name:A
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 YELLOWTAIL RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-6102
Mailing Address - Country:US
Mailing Address - Phone:307-632-2480
Mailing Address - Fax:
Practice Address - Street 1:6900 YELLOWTAIL RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6102
Practice Address - Country:US
Practice Address - Phone:307-632-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30368390200000X
WY13691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program