# FOUR CORNERS ORAL AND MAXILLIOFACIAL SURGERY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104162452
- **Authorized official:** DR. MICHAEL WALTER JOHNSON M.D,DDS (PRESIDENT)
- **Authorized official phone:** (970) 385-5432

## Contact information

- **Practice address:** 72 SUTTLE ST, S\# E, DURANGO, CO 81303-6829
- **Practice address phone:** (970) 385-5432
- **Practice address fax:** (970) 385-5077
- **Mailing address:** 72 SUTTLE ST, S\# E, DURANGO, CO 81303-6829
- **Mailing address phone:** (970) 385-5432
- **Mailing address fax:** (970) 385-5077

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QD0000X | Dental Clinic/Center | C36335 | CO | Yes |

## Other

- **Enumeration date:** 12/13/2012
- **Last updated:** 12/13/2012