Provider Demographics
NPI:1487767497
Name:WEAVER, TIMOTHY JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAY
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21701 76TH AVE W
Mailing Address - Street 2:202
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7536
Mailing Address - Country:US
Mailing Address - Phone:425-744-1724
Mailing Address - Fax:425-744-1726
Practice Address - Street 1:21701 76TH AVE W
Practice Address - Street 2:202
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7536
Practice Address - Country:US
Practice Address - Phone:425-744-1724
Practice Address - Fax:425-744-1726
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000067241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU37729Medicare UPIN