Provider Demographics
NPI:1336260769
Name:PERFECT TEETH - FOURTH STREET P.C.
Entity Type:Organization
Organization Name:PERFECT TEETH - FOURTH STREET P.C.
Other - Org Name:PERFECT TEETH - FOURTH STREET P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-285-6098
Mailing Address - Street 1:5721 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5302
Mailing Address - Country:US
Mailing Address - Phone:505-345-0515
Mailing Address - Fax:505-345-2418
Practice Address - Street 1:5721 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5302
Practice Address - Country:US
Practice Address - Phone:505-345-0515
Practice Address - Fax:505-345-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM13981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty