Provider Demographics
NPI:1871694380
Name:WEIL, JACK (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:WEIL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 MAPLE AVE WEST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-255-2573
Mailing Address - Fax:703-255-2278
Practice Address - Street 1:402 MAPLE AVE WEST
Practice Address - Street 2:SUITE B
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-255-2573
Practice Address - Fax:703-255-2278
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010055511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry