Provider Demographics
NPI:1619363694
Name:CANYON DENTAL GROUP, PLLC
Entity Type:Organization
Organization Name:CANYON DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERKLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-323-2600
Mailing Address - Street 1:4001 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3454
Mailing Address - Country:US
Mailing Address - Phone:520-323-2600
Mailing Address - Fax:520-323-2800
Practice Address - Street 1:4001 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3454
Practice Address - Country:US
Practice Address - Phone:520-323-2600
Practice Address - Fax:520-323-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty