Basic Information
| Provider Information | |||||||||
| NPI: | 1669795456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR CORNERS FAMILY DENTAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 N BUTLER AVE STE 114 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874016429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055644470 | ||||||||
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| Practice Location | |||||||||
| Address1: | 383 CANYONVIEW DR | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874018629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055644470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 5055644470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.