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NPI Code Detail

MEDICARE: DR. JACK H WEAVER DDS

MEDICARE: DR. JACK H WEAVER DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryM366SD

General Provider Information

NPI Number : 1043238389
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JACK H WEAVER DDS
Provider Business Mailing Address
First Line : 4716 GUEST RD
Second Line :
City : RAPID CITY
State : SD
Zip : 57702-4815
Country : US
Telephone Number : 605-484-4484
Fax Number : 605-341-2766
Provider Business Practice Location Address
First Line : 3712 CANYON LAKE DR
Second Line :
City : RAPID CITY
State : SD
Zip : 57702-3198
Country : US
Telephone Number : 605-342-3939
Fax Number : 605-341-2766
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2006
Last Update Date : 07/08/2007

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Directions to “ DR. JACK H WEAVER DDS” Practice Location

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