MEDICARE: MR. MICHAEL DON 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
1	122300000X	Dentist	4275	OK

General Provider Information

NPI Number	:	1104978428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL DON WEAVER DDS

Provider Business Mailing Address
First Line	:	PO BOX 1270
Second Line	:	16931 HWY 70
City	:	LONE GROVE
State	:	OK
Zip	:	73443-1270
Country	:	US
Telephone Number	:	580-657-3117
Fax Number	:	580-657-8081

Provider Business Practice Location Address
First Line	:	16931 HWY 70
Second Line	:
City	:	LONE GROVE
State	:	OK
Zip	:	73443-1270
Country	:	US
Telephone Number	:	580-657-3117
Fax Number	:	580-657-8081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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