Healthcare Provider Details

I. General information

NPI: 1528175494
Provider Name (Legal Business Name): MICHAEL B WEISS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SOUTH CEDAR ST
HAZLETON PA
18201-6602
US

IV. Provider business mailing address

14 SOUTH CEDAR ST
HAZLETON PA
18201-6602
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-6275
  • Fax: 570-455-6276
Mailing address:
  • Phone: 570-455-6275
  • Fax: 570-455-6276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS021559L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier91848
Identifier TypeOTHER
Identifier State
Identifier IssuerUNISON HEALTH PLAN
# 2
Identifier0008010
Identifier TypeOTHER
Identifier State
Identifier IssuerDORAL DENTAL
# 3
Identifier000769058
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier137905
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED CONCORDIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: