=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063886281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEISNER ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2015
-----------------------------------------------------
Last Update Date | 11/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126A PLEASANT VALLEY ST
-----------------------------------------------------
City | METHUEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01844-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-683-3433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126A PLEASANT VALLEY ST
-----------------------------------------------------
City | METHUEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01844-7217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-683-2433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPRIETOR
-----------------------------------------------------
Name | DR. STEPHEN WEISNER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 978-683-3433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 13497
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------