1194048744 NPI number — CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP

Table of content: (NPI 1194048744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194048744 NPI number — CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194048744
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2860 MICHELLE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92606-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-368-2077
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25155 N 67TH AVE STE 142
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85083-1065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-561-6767
Provider Business Practice Location Address Fax Number:
623-561-1703
Provider Enumeration Date:
03/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COCKRELL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
626-561-6767

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com