Healthcare Provider Details

I. General information

NPI: 1154463552
Provider Name (Legal Business Name): DAVID L WEISS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 WEST B BLDG G
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

175 WEST B ST BLDG G
SPRINGFIELD OR
97477
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-0101
  • Fax: 541-747-6494
Mailing address:
  • Phone: 541-747-0101
  • Fax: 541-747-6494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5571
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: