Healthcare Provider Details

I. General information

NPI: 1104162452
Provider Name (Legal Business Name): FOUR CORNERS ORAL AND MAXILLIOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 SUTTLE ST S# E
DURANGO CO
81303-6829
US

IV. Provider business mailing address

72 SUTTLE ST S# E
DURANGO CO
81303-6829
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-5432
  • Fax: 970-385-5077
Mailing address:
  • Phone: 970-385-5432
  • Fax: 970-385-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberC36335
License Number StateCO

VIII. Authorized Official

Name: DR. MICHAEL WALTER JOHNSON
Title or Position: PRESIDENT
Credential: M.D,DDS
Phone: 970-385-5432