Provider Demographics
NPI:1487024865
Name:SAN JUAN DENTAL CLINIC PC
Entity Type:Organization
Organization Name:SAN JUAN DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-565-4448
Mailing Address - Street 1:115 N BEECH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3207
Mailing Address - Country:US
Mailing Address - Phone:970-565-4448
Mailing Address - Fax:970-565-7211
Practice Address - Street 1:115 N BEECH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3207
Practice Address - Country:US
Practice Address - Phone:970-565-4448
Practice Address - Fax:970-565-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty