Provider Demographics
NPI:1083048011
Name:GERALD K. WEAVER, D.M.D. AND MICHAEL STRATTON, D.M.D., PEDIATRIC DENTI
Entity type:Organization
Organization Name:GERALD K. WEAVER, D.M.D. AND MICHAEL STRATTON, D.M.D., PEDIATRIC DENTI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-264-5437
Mailing Address - Street 1:3030 HARTLEY RD STE 310
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8213
Mailing Address - Country:US
Mailing Address - Phone:904-264-5437
Mailing Address - Fax:904-485-8417
Practice Address - Street 1:3030 HARTLEY RD STE 310
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8213
Practice Address - Country:US
Practice Address - Phone:904-264-5437
Practice Address - Fax:904-485-8417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty