Provider Demographics
NPI:1821196197
Name:CANYON RIVER DENTAL
Entity Type:Organization
Organization Name:CANYON RIVER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-221-5859
Mailing Address - Street 1:3707 N CANYON RD
Mailing Address - Street 2:SUITE 7D
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-221-5859
Mailing Address - Fax:801-221-7091
Practice Address - Street 1:3707 N CANYON RD
Practice Address - Street 2:SUITE 7D
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-221-5859
Practice Address - Fax:801-221-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3124349922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529578391004Medicaid