Provider Demographics
NPI:1639380363
Name:BLACK CANYON CITY DENTISTRY LLC
Entity Type:Organization
Organization Name:BLACK CANYON CITY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-374-0855
Mailing Address - Street 1:PO BOX #7
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324
Mailing Address - Country:US
Mailing Address - Phone:623-374-0855
Mailing Address - Fax:623-374-0854
Practice Address - Street 1:34501 S OLD BLACK CANYON CITY HIGHWAY
Practice Address - Street 2:SUITE 5
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324
Practice Address - Country:US
Practice Address - Phone:623-374-0855
Practice Address - Fax:623-374-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ05797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty