Provider Demographics
NPI:1730232588
Name:FOUR CORNERS ORTHODONTICS CENTERS INC
Entity type:Organization
Organization Name:FOUR CORNERS ORTHODONTICS CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORHTODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
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
Mailing Address - Street 2:SUITE 113
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6435
Mailing Address - Country:US
Mailing Address - Phone:505-564-9000
Mailing Address - Fax:505-564-9100
Practice Address - Street 1:3751 N BUTLER AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6435
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:2007-01-18
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD18591223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty