Healthcare Provider Details

I. General information

NPI: 1982229985
Provider Name (Legal Business Name): KOLIN E. WEAVER, DDS, MS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 RED WOLF BLVD STE C
JONESBORO AR
72401-6360
US

IV. Provider business mailing address

2316 RED WOLF BLVD STE C
JONESBORO AR
72401-6360
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-5445
  • Fax:
Mailing address:
  • Phone: 870-972-5445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KOLIN EMRYS WEAVER
Title or Position: PRESIDENT/ ORTHODONTIST
Credential: DDS
Phone: 870-972-5445