=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659915437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEIMER DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2019
-----------------------------------------------------
Last Update Date | 11/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8336 W NORTHVIEW ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-7132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-375-4544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 186 MOUNTAIN VISTA AVE SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97306-9168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-805-0389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TRAVIS JON WEIMER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 541-805-0389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------