Provider Demographics
NPI:1619216355
Name:BENJAMIN D. SMITH OD, LLC
Entity Type:Organization
Organization Name:BENJAMIN D. SMITH OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:720-255-2412
Mailing Address - Street 1:1041 ACOMA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4034
Mailing Address - Country:US
Mailing Address - Phone:720-255-2412
Mailing Address - Fax:720-536-8283
Practice Address - Street 1:1041 ACOMA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4034
Practice Address - Country:US
Practice Address - Phone:720-255-2412
Practice Address - Fax:720-536-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT2881152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO361377Medicare PIN