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General NPI Number Information
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NPI Number | 1437435781
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Entity Type | Organization
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Legal Business Name | AWL DENTISTRY PC
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Dates
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Enumeration Date | 11/01/2011
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Last Update Date | 11/01/2011
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Provider Practice Location Address
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Address Line | 170 S CREASY LN STE 1730
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City | LAFAYETTE
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State | IN
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Zip | 47905-0759
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Country | US
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Telephone | 765-913-9070
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Fax |
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Provider Business Mailing Address
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Address Line | 3974 BELL CT
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City | NAMPA
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State | ID
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Zip | 83686-1411
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Country | US
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Telephone | 208-284-0054
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES R WEAVER
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Credential | DDS
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Telephone | 208-284-0054
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12011732A
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License Number State | IN
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