Provider Demographics
NPI:1366430647
Name:WEEDA, LAWRENCE W JR (DDS)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:WEEDA
Suffix:JR
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 1:875 UNION AVE
Mailing Address - Street 2:ROOM N-328
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-0001
Mailing Address - Country:US
Mailing Address - Phone:901-448-6236
Mailing Address - Fax:901-448-5480
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:ROOM N-328
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-6236
Practice Address - Fax:901-448-5480
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS74411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU70869Medicare UPIN
TN3226310Medicare ID - Type Unspecified