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General NPI Number Information
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NPI Number | 1922599240
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Entity Type | Organization
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Legal Business Name | CANYON DENTAL INC.
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Dates
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Enumeration Date | 05/22/2018
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 2219 S HACIENDA BLVD STE 202
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City | HACIENDA HEIGHTS
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State | CA
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Zip | 91745-4610
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Country | US
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Telephone | 626-369-8617
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Fax | 626-369-0257
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Provider Business Mailing Address
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Address Line | 2219 S HACIENDA BLVD STE 202
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City | HACIENDA HEIGHTS
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State | CA
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Zip | 91745-4610
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Country | US
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Telephone | 626-369-8617
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Fax | 626-369-0257
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Authorized Official
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Title or Position | DENTIST
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Name | GABRIEL DE LA VARA
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Credential |
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Telephone | 626-369-8617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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