Healthcare Provider Details

I. General information

NPI: 1477272151
Provider Name (Legal Business Name): JOHN K WEAVER, DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 PROFESSIONAL DR
BRUNSWICK GA
31520-3773
US

IV. Provider business mailing address

35 PROFESSIONAL DR
BRUNSWICK GA
31520-3773
US

V. Phone/Fax

Practice location:
  • Phone: 912-264-6890
  • Fax: 912-264-4374
Mailing address:
  • Phone: 912-264-6890
  • Fax: 912-264-4374

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: VICENTA REYES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 972-869-3789