Basic Information
| Provider Information | |||||||||
| NPI: | 1003295478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR CORNERS FAMILY DENTAL-CO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 N BUTLER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053202942 | ||||||||
| FaxNumber: | 5053259707 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 N PAGOSA ST | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705071300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5053202942 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUR CORNERS FAMILY DENTAL, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.0000111 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.