MEDICARE: CLINTON E WEAVER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	28254	CA

General Provider Information

NPI Number	:	1407957947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON E WEAVER DDS

Provider Business Mailing Address
First Line	:	1202 FARMERS LN
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6707
Country	:	US
Telephone Number	:	707-526-7036
Fax Number	:	707-526-4569

Provider Business Practice Location Address
First Line	:	1202 FARMERS LN
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6707
Country	:	US
Telephone Number	:	707-526-7036
Fax Number	:	707-526-4569

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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Directions to “ CLINTON E WEAVER DDS” Practice Location

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