MEDICARE: CANYON CREEK FAMILY DENTISTRY, P.A.

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	1223P0221X	Pediatric Dentistry	24260	TX
2	1223G0001X	General Practice Dentistry	20074	TX

General Provider Information

NPI Number	:	1659502730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON CREEK FAMILY DENTISTRY, P.A.

Provider Business Mailing Address
First Line	:	2091 N COLLINS BLVD STE 100
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-2636
Country	:	US
Telephone Number	:	972-644-3800
Fax Number	:	972-644-3888

Provider Business Practice Location Address
First Line	:	2091 N COLLINS BLVD STE 100
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-2636
Country	:	US
Telephone Number	:	972-644-3800
Fax Number	:	972-644-3888

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AFSHIN AZMOODEH
Credential	:	D.D.S.
Telephone Number	:	972-644-3800

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	08/06/2009

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Directions to “CANYON CREEK FAMILY DENTISTRY, P.A. ” Practice Location

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