Provider Demographics
NPI:1366848897
Name:CANYON MODERN DENTISTRY & ORTHODONTICS
Entity Type:Organization
Organization Name:CANYON MODERN DENTISTRY & ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:KHAKWANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:316-727-6886
Mailing Address - Street 1:17081 W GREENWAY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-9612
Mailing Address - Country:US
Mailing Address - Phone:623-546-8400
Mailing Address - Fax:623-214-5830
Practice Address - Street 1:17081 W GREENWAY RD
Practice Address - Street 2:SUITE 120
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:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009075261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental