Provider Demographics
NPI:1285853671
Name:BCKK 83RD AND CAMELBACK LLC
Entity Type:Organization
Organization Name:BCKK 83RD AND CAMELBACK LLC
Other - Org Name:COYOTE RIDGE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-917-0181
Mailing Address - Street 1:8141 W CAMELBACK RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-1050
Mailing Address - Country:US
Mailing Address - Phone:623-848-9100
Mailing Address - Fax:623-247-3917
Practice Address - Street 1:8141 W CAMELBACK RD
Practice Address - Street 2:SUITE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-1050
Practice Address - Country:US
Practice Address - Phone:623-848-9100
Practice Address - Fax:623-247-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1808900OtherUCCI
AZ002Medicare ID - Type UnspecifiedMERCY CARE
AZF14882Medicare ID - Type UnspecifiedPHEONIX HEALTH PLAN