Provider Demographics
NPI:1659502730
Name:CANYON CREEK FAMILY DENTISTRY, P.A.
Entity Type:Organization
Organization Name:CANYON CREEK FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AFSHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZMOODEH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-644-3800
Mailing Address - Street 1:2091 N COLLINS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2636
Mailing Address - Country:US
Mailing Address - Phone:972-644-3800
Mailing Address - Fax:972-644-3888
Practice Address - Street 1:2091 N COLLINS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2636
Practice Address - Country:US
Practice Address - Phone:972-644-3800
Practice Address - Fax:972-644-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200741223G0001X
TX242601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty