Healthcare Provider Details

I. General information

NPI: 1104789809
Provider Name (Legal Business Name): DEXTER CANOY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

1636 CHERRY TREE PL
UPLAND CA
91784-2530
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 626-510-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number95292177
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95292177
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WX0601X
TaxonomyOtorhinolaryngology & Head-Neck Registered Nurse
License Number95292177
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95292177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: