Provider Demographics
NPI:1922599240
Name:CANYON DENTAL INC.
Entity Type:Organization
Organization Name:CANYON DENTAL INC.
Other - Org Name:CANYON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA VARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-369-8617
Mailing Address - Street 1:2219 S HACIENDA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4610
Mailing Address - Country:US
Mailing Address - Phone:626-369-8617
Mailing Address - Fax:626-369-0257
Practice Address - Street 1:2219 S HACIENDA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-4610
Practice Address - Country:US
Practice Address - Phone:626-369-8617
Practice Address - Fax:626-369-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty