Healthcare Provider Details

I. General information

NPI: 1396777652
Provider Name (Legal Business Name): ROBERT MICHAEL WEISS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W AVON RD
AVON CT
06001-3677
US

IV. Provider business mailing address

20 W AVON RD
AVON CT
06001-3677
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-0451
  • Fax: 860-673-6784
Mailing address:
  • Phone: 860-673-0451
  • Fax: 860-673-6784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3855
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: