Provider Demographics
NPI:1245666908
Name:GRAND CANYON DENTAL, PLLC
Entity type:Organization
Organization Name:GRAND CANYON DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEPLINSKIS MUKTANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-323-4699
Mailing Address - Street 1:PO BOX 32067
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2067
Mailing Address - Country:US
Mailing Address - Phone:602-323-4699
Mailing Address - Fax:
Practice Address - Street 1:2610 W BASELINE RD STE 118
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6400
Practice Address - Country:US
Practice Address - Phone:602-323-4699
Practice Address - Fax:602-323-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty