Healthcare Provider Details

I. General information

NPI: 1417013640
Provider Name (Legal Business Name): TREVOR ROY WEATHERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 NW 5TH ST SUITE 102
PLANTATION FL
33317-2158
US

IV. Provider business mailing address

4141 NW 5TH ST SUITE 102
PLANTATION FL
33317-2158
US

V. Phone/Fax

Practice location:
  • Phone: 954-791-1220
  • Fax: 954-791-0631
Mailing address:
  • Phone: 954-791-1220
  • Fax: 954-791-0631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN 11394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: