MEDICARE: JOHN T WEAVER DMD PC

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	10938	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164859344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN T WEAVER DMD PC

Provider Business Mailing Address
First Line	:	2797 CAMPBELLTON RD SW
Second Line	:	SUITE A4
City	:	ATLANTA
State	:	GA
Zip	:	30311-4455
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2797 CAMPBELLTON RD SW
Second Line	:	SUITE A4
City	:	ATLANTA
State	:	GA
Zip	:	30311-4455
Country	:	US
Telephone Number	:	404-346-1120
Fax Number	:

Authorized Official
Title or Position	:	PRES.
Name	:	JOHN WEAVER
Credential	:	D.M.D.
Telephone Number	:	404-346-1120

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	10/02/2013

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