=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164859344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN T WEAVER DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2013
-----------------------------------------------------
Last Update Date | 10/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2797 CAMPBELLTON RD SW SUITE A4
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-346-1120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2797 CAMPBELLTON RD SW SUITE A4
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-4455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES.
-----------------------------------------------------
Name | JOHN WEAVER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 404-346-1120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10938
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------