Basic Information
| Provider Information | |||||||||
| NPI: | 1205029139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | WELLS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38717 38TH STREET | ||||||||
| Address2: | USA DENTAC | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 ARMY BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210826 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS037167 | PA | N | Dental Providers | Dentist | 1223X0400X | DS037167 | PA | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.