Provider Demographics
NPI:1194021170
Name:CANYON MODERN DENTISTRY, LLP
Entity Type:Organization
Organization Name:CANYON MODERN DENTISTRY, LLP
Other - Org Name:CANYON MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-546-8400
Mailing Address - Street 1:2860 MICHELLE DRIVE 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:17081 W GREENWAY RD STE 121
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9612
Practice Address - Country:US
Practice Address - Phone:623-546-8400
Practice Address - Fax:623-214-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty