Healthcare Provider Details

I. General information

NPI: 1073052072
Provider Name (Legal Business Name): CANYON DENTAL IMPLANT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 S TOWN CENTER DR
LAS VEGAS NV
89135-3017
US

IV. Provider business mailing address

6200 N DURANGO DR STE 100
LAS VEGAS NV
89149-3916
US

V. Phone/Fax

Practice location:
  • Phone: 702-660-5576
  • Fax: 702-660-5590
Mailing address:
  • Phone: 702-660-5574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE FALK
Title or Position: MEMBER
Credential: DMD
Phone: 702-660-5574