Provider Demographics
NPI:1124280342
Name:WEAVER, LORETTA T (RDH)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:T
Last Name:WEAVER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 2224
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:32309-2897
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3385 CAMERON CHASE DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-2897
Practice Address - Country:US
Practice Address - Phone:850-933-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-29
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905587124Q00000X
FLDH18720124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist