Healthcare Provider Details

I. General information

NPI: 1518340694
Provider Name (Legal Business Name): RUBY CANYON DENTAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 PATTERSON RD
GRAND JUNCTION CO
81505-1423
US

IV. Provider business mailing address

2552 PATTERSON RD
GRAND JUNCTION CO
81505-1423
US

V. Phone/Fax

Practice location:
  • Phone: 970-241-1313
  • Fax: 970-241-5202
Mailing address:
  • Phone: 970-241-1313
  • Fax: 970-241-5202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DEREK DEAN
Title or Position: DENTIST
Credential: DDS
Phone: 970-261-3004