Provider Demographics
NPI:1255835187
Name:CANYON CREST FAMILY DENTAL & AESTHETICS
Entity type:Organization
Organization Name:CANYON CREST FAMILY DENTAL & AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-924-8858
Mailing Address - Street 1:332 S ORCHARD SPRINGS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6154
Mailing Address - Country:US
Mailing Address - Phone:719-924-8858
Mailing Address - Fax:
Practice Address - Street 1:332 S ORCHARD SPRINGS DR STE 110
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-6154
Practice Address - Country:US
Practice Address - Phone:719-924-8858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00202790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07178506Medicaid