Provider Demographics
NPI:1821425406
Name:CANYON VIEW DENTAL
Entity Type:Organization
Organization Name:CANYON VIEW DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JR
Authorized Official - Middle Name:
Authorized Official - Last Name:DETHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-816-9366
Mailing Address - Street 1:2680 E BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5603
Mailing Address - Country:US
Mailing Address - Phone:801-816-9366
Mailing Address - Fax:
Practice Address - Street 1:1844 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-3000
Practice Address - Country:US
Practice Address - Phone:801-816-9366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty