Healthcare Provider Details

I. General information

NPI: 1891311379
Provider Name (Legal Business Name): JONATHAN FREDERICK WEAVER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEADQUARTERS UNITED STATES ARMY DENTAL HEALTH ACTIVITY 4323 HILL STREET
APO AA
29207-6022
US

IV. Provider business mailing address

302 MEADOWCREST DR
TRUCKSVILLE PA
18708-9481
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-3255
  • Fax:
Mailing address:
  • Phone: 570-574-5813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042725
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: