Provider Demographics
NPI:1871645051
Name:THORNAL, BENJAMIN CAMPBELL IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:CAMPBELL
Last Name:THORNAL
Suffix:IV
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 1:1512 GRAND AVE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-3861
Mailing Address - Country:US
Mailing Address - Phone:970-947-1273
Mailing Address - Fax:970-928-0741
Practice Address - Street 1:1512 GRAND AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-3861
Practice Address - Country:US
Practice Address - Phone:970-947-1273
Practice Address - Fax:970-928-0741
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO92961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice