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General NPI Number Information
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NPI Number | 1104162452
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Entity Type | Organization
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Legal Business Name | FOUR CORNERS ORAL AND MAXILLIOFACIAL SURGERY
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Dates
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Enumeration Date | 12/13/2012
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Last Update Date | 12/13/2012
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Provider Practice Location Address
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Address Line | 72 SUTTLE ST S# E
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City | DURANGO
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State | CO
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Zip | 81303-6829
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Country | US
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Telephone | 970-385-5432
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Fax | 970-385-5077
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Provider Business Mailing Address
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Address Line | 72 SUTTLE ST S# E
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City | DURANGO
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State | CO
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Zip | 81303-6829
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Country | US
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Telephone | 970-385-5432
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Fax | 970-385-5077
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL WALTER JOHNSON
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Credential | M.D,DDS
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Telephone | 970-385-5432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | C36335
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License Number State | CO
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