Healthcare Provider Details

I. General information

NPI: 1801558150
Provider Name (Legal Business Name): IAN MONTGOMERY WEAVER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 SUNCREST TOWN CENTRE DR
MORGANTOWN WV
26505-1814
US

IV. Provider business mailing address

31 CHERRY WOOD DR
MORGANTOWN WV
26508-4237
US

V. Phone/Fax

Practice location:
  • Phone: 304-541-2284
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4468
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10909
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: