Healthcare Provider Details

I. General information

NPI: 1669787974
Provider Name (Legal Business Name): ADAM B WEAVER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 07/30/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W. BROADWAY
AVA MO
65608
US

IV. Provider business mailing address

PO BOX 1359
AVA MO
65608-1359
US

V. Phone/Fax

Practice location:
  • Phone: 417-683-5739
  • Fax:
Mailing address:
  • Phone: 417-683-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2023015375
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1351
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: