Provider Demographics
NPI:1114194651
Name:DESERT CANYON DENTISTRY PLLC
Entity Type:Organization
Organization Name:DESERT CANYON DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DITTERLINE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-661-1200
Mailing Address - Street 1:13910 N FRANK LLOYD WRIGHT BLVD
Mailing Address - Street 2:STE 3
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-661-1200
Mailing Address - Fax:480-661-1729
Practice Address - Street 1:13910 N FRANK LLOYD WRIGHT BLVD
Practice Address - Street 2:STE 3
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-661-1200
Practice Address - Fax:480-661-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD43951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty