Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 17055 | TX |
N | 1223D0004X | Dentist Anesthesiologist | 17055 | TX |
N | 1223G0001X | General Practice | 17055 | TX |
N | 213EG0000X | General Practice | 17055 | TX |
NPI | 1982088530 |
---|---|
Provider Name | Dr. Michael David Weaks |
First Address | Greenville, TX 75401 |
Second Address | Greenville, TX 75401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2015 |
Last Update Date | 14/07/2015 |