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NPI Code Detail

MEDICARE: CANYON VIEW DENTAL

MEDICARE: CANYON VIEW DENTAL
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
1122300000XDentist

General Provider Information

NPI Number : 1821425406
Entity Type Code : Organization
Provider Name (Legal Business Name) : CANYON VIEW DENTAL
Provider Business Mailing Address
First Line : 2680 E BRIDGEPORT AVE
Second Line :
City : COTTONWOOD HEIGHTS
State : UT
Zip : 84121-5603
Country : US
Telephone Number : 801-816-9366
Fax Number :
Provider Business Practice Location Address
First Line : 1844 E 9400 S
Second Line :
City : SANDY
State : UT
Zip : 84093-3000
Country : US
Telephone Number : 801-816-9366
Fax Number :
Authorized Official
Title or Position : OWNER
Name : MR. JR DETHORN
Credential :
Telephone Number : 801-816-9366
Provider Enumeration Date : 09/27/2013
Last Update Date : 09/27/2013

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Directions to “CANYON VIEW DENTAL ” Practice Location

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