MEDICARE: DR. WILLIAM RANDAL WEBER D.D.S.

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	3874	OK

General Provider Information

NPI Number	:	1164562997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM RANDAL WEBER D.D.S.

Provider Business Mailing Address
First Line	:	1216 E HARTFORD AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2017
Country	:	US
Telephone Number	:	580-762-9119
Fax Number	:

Provider Business Practice Location Address
First Line	:	1216 E HARTFORD AVE
Second Line	:	SUITE 1A
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2017
Country	:	US
Telephone Number	:	580-762-9119
Fax Number	:	580-762-9118

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	09/05/2007

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