MEDICARE: DR. TIMOTHY JAY 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DE00006724	WA

General Provider Information

NPI Number	:	1487767497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY JAY WEAVER DDS

Provider Business Mailing Address
First Line	:	21701 76TH AVE W
Second Line	:	202
City	:	EDMONDS
State	:	WA
Zip	:	98026-7536
Country	:	US
Telephone Number	:	425-744-1724
Fax Number	:	425-744-1726

Provider Business Practice Location Address
First Line	:	21701 76TH AVE W
Second Line	:	202
City	:	EDMONDS
State	:	WA
Zip	:	98026-7536
Country	:	US
Telephone Number	:	425-744-1724
Fax Number	:	425-744-1726

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/08/2007

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