Provider Demographics
NPI:1225364607
Name:FOUR CORNERS SMILES 4 KIDS, INC.
Entity Type:Organization
Organization Name:FOUR CORNERS SMILES 4 KIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-247-0202
Mailing Address - Street 1:1135 S CAMINO DEL RIO
Mailing Address - Street 2:STE. 210
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6831
Mailing Address - Country:US
Mailing Address - Phone:970-247-0202
Mailing Address - Fax:970-247-0404
Practice Address - Street 1:1135 S CAMINO DEL RIO
Practice Address - Street 2:STE. 210
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6831
Practice Address - Country:US
Practice Address - Phone:970-247-0202
Practice Address - Fax:970-247-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty