Basic Information
| Provider Information | |||||||||
| NPI: | 1285252627 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 3501 NORTH BUTLER AVENUE FARMINGTON PROFESSIONAL LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOUR CORNERS FAMILY DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 N BUTLER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874016430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055644470 | ||||||||
| FaxNumber: | 5053259707 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 N BUTLER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874016430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055644470 | ||||||||
| FaxNumber: | 5053259707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRUMBOS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5055644470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.