Provider Demographics
NPI:1104162452
Name:FOUR CORNERS ORAL AND MAXILLIOFACIAL SURGERY
Entity type:Organization
Organization Name:FOUR CORNERS ORAL AND MAXILLIOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DDS
Authorized Official - Phone:970-385-5432
Mailing Address - Street 1:72 SUTTLE ST
Mailing Address - Street 2:S# E
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6829
Mailing Address - Country:US
Mailing Address - Phone:970-385-5432
Mailing Address - Fax:970-385-5077
Practice Address - Street 1:72 SUTTLE ST
Practice Address - Street 2:S# E
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6829
Practice Address - Country:US
Practice Address - Phone:970-385-5432
Practice Address - Fax:970-385-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC36335261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG87185Medicare UPIN
COC46741Medicare PIN