Provider Demographics
NPI:1558790378
Name:DR DAVID HERMAN'S FOUR CORNERS DENTAL, LLC
Entity Type:Organization
Organization Name:DR DAVID HERMAN'S FOUR CORNERS DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, MPH
Authorized Official - Phone:505-564-9000
Mailing Address - Street 1:3751 N BUTLER AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6425
Mailing Address - Country:US
Mailing Address - Phone:505-564-9000
Mailing Address - Fax:505-564-9100
Practice Address - Street 1:3751 N BUTLER AVE STE 113
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6425
Practice Address - Country:US
Practice Address - Phone:505-564-9000
Practice Address - Fax:505-564-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty