Healthcare Provider Details

I. General information

NPI: 1023786241
Provider Name (Legal Business Name): JONATHAN DAVID WEBER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 N LYNNDALE DR STE 1A
APPLETON WI
54914-3085
US

IV. Provider business mailing address

1435 N MCCARTHY RD APT 5
APPLETON WI
54913-8285
US

V. Phone/Fax

Practice location:
  • Phone: 920-450-4378
  • Fax:
Mailing address:
  • Phone: 920-450-4378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002696-15
License Number StateWI

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: