MEDICARE: DR. STEPHANIE 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	5170	LA

General Provider Information

NPI Number	:	1750592713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE WEAVER DDS

Provider Business Mailing Address
First Line	:	715 W COLLEGE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1523
Country	:	US
Telephone Number	:	337-478-3123
Fax Number	:	337-478-3229

Provider Business Practice Location Address
First Line	:	715 W COLLEGE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-1523
Country	:	US
Telephone Number	:	337-478-3123
Fax Number	:	337-478-3229

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	05/28/2024

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