Provider Demographics
NPI:1073052072
Name:CANYON DENTAL IMPLANT CENTER LLC
Entity Type:Organization
Organization Name:CANYON DENTAL IMPLANT CENTER LLC
Other - Org Name:CANYON DENTAL IMPLANTS & DENTURES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FALK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-660-5574
Mailing Address - Street 1:6200 N DURANGO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-3916
Mailing Address - Country:US
Mailing Address - Phone:702-660-5574
Mailing Address - Fax:
Practice Address - Street 1:3635 S TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-3017
Practice Address - Country:US
Practice Address - Phone:702-660-5576
Practice Address - Fax:702-660-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental