Healthcare Provider Details

I. General information

NPI: 1760409213
Provider Name (Legal Business Name): WALTER A WEAVER JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 SALEM ST WA WEAVER DDS
SWAMPSCOTT MA
01907-1306
US

IV. Provider business mailing address

230 SALEM ST WA WEAVER DDS
SWAMPSCOTT MA
01907-1306
US

V. Phone/Fax

Practice location:
  • Phone: 781-581-1550
  • Fax: 781-592-8549
Mailing address:
  • Phone: 781-581-1550
  • Fax: 781-592-8549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12253
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: