Provider Demographics
NPI:1912395302
Name:STOCKTON 22, INC.
Entity Type:Organization
Organization Name:STOCKTON 22, INC.
Other - Org Name:COPPER CANYON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-830-9081
Mailing Address - Street 1:6830 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1456
Mailing Address - Country:US
Mailing Address - Phone:505-830-9081
Mailing Address - Fax:505-830-9086
Practice Address - Street 1:6830 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1456
Practice Address - Country:US
Practice Address - Phone:505-830-9081
Practice Address - Fax:505-830-9086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty