MEDICARE: BLACK CANYON DENTAL P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1679732804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK CANYON DENTAL P C

Provider Business Mailing Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3860
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3535
Country	:	US
Telephone Number	:	208-365-3860
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. SHON D ROOKS
Credential	:	D.D.S.
Telephone Number	:	208-365-3860

Provider Enumeration Date	:	06/03/2008
Last Update Date	:	06/05/2008

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