=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538236054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R TODD WEAVER, DMD & JOHN L RECKNER ,DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 03/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 775 ROUTE 113
-----------------------------------------------------
City | SOUDERTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18964-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-723-2162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 775 ROUTE 113
-----------------------------------------------------
City | SOUDERTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18964-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-723-2162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | TARA AYERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-723-2162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------