1003295478 NPI number — FOUR CORNERS FAMILY DENTAL-CO, LLC

Table of content: (NPI 1003295478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003295478 NPI number — FOUR CORNERS FAMILY DENTAL-CO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS FAMILY DENTAL-CO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003295478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3501 N BUTLER AVE STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-320-2942
Provider Business Mailing Address Fax Number:
505-325-9707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 N PAGOSA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAGOSA SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-507-1300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MANN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
505-320-2942

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DEN.0000111 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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