Provider Demographics
NPI:1104978428
Name:WEAVER, MICHAEL DON (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:16931 HWY 70
Mailing Address - City:LONE GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:73443-1270
Mailing Address - Country:US
Mailing Address - Phone:580-657-3117
Mailing Address - Fax:580-657-8081
Practice Address - Street 1:16931 HWY 70
Practice Address - Street 2:
Practice Address - City:LONE GROVE
Practice Address - State:OK
Practice Address - Zip Code:73443-1270
Practice Address - Country:US
Practice Address - Phone:580-657-3117
Practice Address - Fax:580-657-8081
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist