Provider Demographics
NPI:1265860936
Name:BEAR CANYON FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:BEAR CANYON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREINEL-BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-821-1430
Mailing Address - Street 1:7007 WYOMING BLVD NE STE B2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3982
Mailing Address - Country:US
Mailing Address - Phone:505-821-1430
Mailing Address - Fax:505-821-1442
Practice Address - Street 1:7007 WYOMING BLVD NE STE B2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3982
Practice Address - Country:US
Practice Address - Phone:505-821-1430
Practice Address - Fax:505-821-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD21551223G0001X
NMDD30031223G0001X
NMDD30051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty