MEDICARE: CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1194048744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP

Provider Business Mailing Address
First Line	:	2860 MICHELLE FL 2
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92606-1008
Country	:	US
Telephone Number	:	714-368-2077
Fax Number	:

Provider Business Practice Location Address
First Line	:	25155 N 67TH AVE STE 142
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85083-1065
Country	:	US
Telephone Number	:	626-561-6767
Fax Number	:	623-561-1703

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. TODD R COCKRELL
Credential	:	DMD
Telephone Number	:	626-561-6767

Provider Enumeration Date	:	03/10/2010
Last Update Date	:	03/10/2010

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