Provider Demographics
NPI:1932767092
Name:WEATHERWAX, KAYLA JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:JO
Last Name:WEATHERWAX
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 1:907 S US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2435
Mailing Address - Country:US
Mailing Address - Phone:989-224-7559
Mailing Address - Fax:989-224-2704
Practice Address - Street 1:907 S US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2435
Practice Address - Country:US
Practice Address - Phone:989-225-7559
Practice Address - Fax:989-224-2704
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901023173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist