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General NPI Number Information
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NPI Number | 1659502730
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Entity Type | Organization
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Legal Business Name | CANYON CREEK FAMILY DENTISTRY, P.A.
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Dates
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Enumeration Date | 08/06/2009
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Last Update Date | 08/06/2009
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Provider Practice Location Address
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Address Line | 2091 N COLLINS BLVD STE 100
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City | RICHARDSON
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State | TX
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Zip | 75080-2636
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Country | US
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Telephone | 972-644-3800
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Fax | 972-644-3888
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Provider Business Mailing Address
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Address Line | 2091 N COLLINS BLVD STE 100
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City | RICHARDSON
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State | TX
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Zip | 75080-2636
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Country | US
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Telephone | 972-644-3800
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Fax | 972-644-3888
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AFSHIN AZMOODEH
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Credential | D.D.S.
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Telephone | 972-644-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 24260
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 20074
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License Number State | TX
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