Provider Demographics
NPI:1003295478
Name:FOUR CORNERS FAMILY DENTAL-CO, LLC
Entity Type:Organization
Organization Name:FOUR CORNERS FAMILY DENTAL-CO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-320-2942
Mailing Address - Street 1:3501 N BUTLER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-320-2942
Mailing Address - Fax:505-325-9707
Practice Address - Street 1:308 N PAGOSA ST
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-507-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR CORNERS FAMILY DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.0000111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty