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General NPI Number Information
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NPI Number | 1811479074
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Entity Type | Organization
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Legal Business Name | COPPERMINE DENTAL STUDIO AT MADERA CANYON PLLC
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Dates
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Enumeration Date | 09/04/2018
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Last Update Date | 09/04/2018
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Provider Practice Location Address
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Address Line | 685 S PECAN TREE LN
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City | GREEN VALLEY
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State | AZ
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Zip | 85614-5114
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Country | US
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Telephone | 520-625-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 685 S PECAN TREE LN
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City | GREEN VALLEY
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State | AZ
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Zip | 85614-5114
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Country | US
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Telephone | 520-625-1600
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JUSTIN DUTTON
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Credential | DMD
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Telephone | 520-839-0600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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