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General NPI Number Information
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NPI Number | 1578884235
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Entity Type | Individual
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Provider Name | KELLY WEAVER DDS
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Gender | Male
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Dates
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Enumeration Date | 06/17/2010
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Last Update Date | 03/08/2024
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Provider Practice Location Address
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Address Line | 310 W IDAHO ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-1710
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Country | US
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Telephone | 208-785-2255
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Fax | 208-785-2275
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Provider Business Mailing Address
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Address Line | PO BOX 248
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City | BLACKFOOT
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State | ID
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Zip | 83221-0248
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Country | US
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Telephone | 208-785-2255
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Fax | 208-785-2275
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D4298
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License Number State | ID
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