MEDICARE: DR. WALTER A WEAVER JR. 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	12253	MA

General Provider Information

NPI Number	:	1760409213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER A WEAVER JR. DDS

Provider Business Mailing Address
First Line	:	230 SALEM ST
Second Line	:	WA WEAVER DDS
City	:	SWAMPSCOTT
State	:	MA
Zip	:	01907-1306
Country	:	US
Telephone Number	:	781-581-1550
Fax Number	:	781-592-8549

Provider Business Practice Location Address
First Line	:	230 SALEM ST
Second Line	:	WA WEAVER DDS
City	:	SWAMPSCOTT
State	:	MA
Zip	:	01907-1306
Country	:	US
Telephone Number	:	781-581-1550
Fax Number	:	781-592-8549

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/21/2007

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