Basic Information
| Provider Information | |||||||||
| NPI: | 1669787974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2160 | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838640908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077332273 | ||||||||
| FaxNumber: | 9077331735 | ||||||||
| Practice Location | |||||||||
| Address1: | 6615 COMANCHE ST | ||||||||
| Address2: | |||||||||
| City: | BONNERS FERRY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838058380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082671718 | ||||||||
| FaxNumber: | 9077331735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2010 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1351 | AK | Y | Dental Providers | Dentist |
No ID Information.