Provider Demographics
NPI:1811479074
Name:COPPERMINE DENTAL STUDIO AT MADERA CANYON PLLC
Entity type:Organization
Organization Name:COPPERMINE DENTAL STUDIO AT MADERA CANYON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:520-839-0600
Mailing Address - Street 1:685 S PECAN TREE LN
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-5114
Mailing Address - Country:US
Mailing Address - Phone:520-625-1600
Mailing Address - Fax:
Practice Address - Street 1:685 S PECAN TREE LN
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-5114
Practice Address - Country:US
Practice Address - Phone:520-625-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUSTIN DUTTON DMD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty