Provider Demographics
NPI:1518515212
Name:CANYON VISTA DENTAL
Entity Type:Organization
Organization Name:CANYON VISTA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-2100
Mailing Address - Street 1:230 N FAIRGROUND ROAD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501
Mailing Address - Country:US
Mailing Address - Phone:435-637-2100
Mailing Address - Fax:435-637-5007
Practice Address - Street 1:1993 S FRONTAGE ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-458-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty