Healthcare Provider Details

I. General information

NPI: 1720200645
Provider Name (Legal Business Name): BENJAMIN WHITED DYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

IV. Provider business mailing address

105 29TH ST SE APT 6
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-1337
  • Fax:
Mailing address:
  • Phone: 304-634-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number23836
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23836
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: