Healthcare Provider Details

I. General information

NPI: 1679326938
Provider Name (Legal Business Name): COPPERMINE MADERA CANYON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 S PECAN TREE LN
GREEN VALLEY AZ
85614-5114
US

IV. Provider business mailing address

685 S PECAN TREE LN
GREEN VALLEY AZ
85614-5114
US

V. Phone/Fax

Practice location:
  • Phone: 520-625-1600
  • Fax: 520-838-0865
Mailing address:
  • Phone: 520-625-1600
  • Fax: 520-838-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNY GARCIA ROCHA
Title or Position: SR TEAM LEAD
Credential:
Phone: 972-869-3789