Provider Demographics
NPI:1528175494
Name:WEISS, MICHAEL B (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:WEISS
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 1:14 SOUTH CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-6602
Mailing Address - Country:US
Mailing Address - Phone:570-455-6275
Mailing Address - Fax:570-455-6276
Practice Address - Street 1:14 SOUTH CEDAR ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6602
Practice Address - Country:US
Practice Address - Phone:570-455-6275
Practice Address - Fax:570-455-6276
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021559L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
91848OtherUNISON HEALTH PLAN
0008010OtherDORAL DENTAL
PA000769058Medicaid
137905OtherUNITED CONCORDIA