MEDICARE: BENJAMIN G WEIR DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	10001	CO

General Provider Information

NPI Number	:	1164596011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN G WEIR DDS

Provider Business Mailing Address
First Line	:	1580 SPACE CENTER DR
Second Line	:	SUITE 107
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2445
Country	:	US
Telephone Number	:	719-574-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1580 SPACE CENTER DR
Second Line	:	SUITE 107
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2445
Country	:	US
Telephone Number	:	719-574-8922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	09/23/2013

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