Healthcare Provider Details

I. General information

NPI: 1366435117
Provider Name (Legal Business Name): RICHARD LEE WEBER JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 JO DOTSON CIR
CLAYTON GA
30525-5007
US

IV. Provider business mailing address

204 LONGVIEW AVE
GAINESVILLE GA
30501-2223
US

V. Phone/Fax

Practice location:
  • Phone: 706-212-0294
  • Fax:
Mailing address:
  • Phone: 770-297-0894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN009212
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: