Provider Demographics
NPI:1902460017
Name:4 CORNERS DENTAL SLEEP SOLUTIONS LLC
Entity Type:Organization
Organization Name:4 CORNERS DENTAL SLEEP SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:VESTAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-565-3612
Mailing Address - Street 1:302 W MONTEZUMA AVE
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 W MONTEZUMA AVE
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2750
Practice Address - Country:US
Practice Address - Phone:970-565-3612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:4 CORNERS DENTAL SLEEP SOLUTIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-24
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies