Provider Demographics
NPI:1164596011
Name:WEIR, BENJAMIN G (DDS)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
Last Name:WEIR
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 1:1580 SPACE CENTER DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-2445
Mailing Address - Country:US
Mailing Address - Phone:719-574-8922
Mailing Address - Fax:
Practice Address - Street 1:1580 SPACE CENTER DR
Practice Address - Street 2:SUITE 107
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-2445
Practice Address - Country:US
Practice Address - Phone:719-574-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist