=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306576749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK CANYON DENTAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2022
-----------------------------------------------------
Last Update Date | 06/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1544 OXBOW DR STE 230
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-5189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-471-3690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3815 AVENUE F
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-7546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-471-3690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANDRE CARDOSO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 801-471-3690
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------