Provider Demographics
NPI:1104282425
Name:CANYON TRAILS FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:CANYON TRAILS FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, CIO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-889-9457
Mailing Address - Street 1:4435 E HOLMES AVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3372
Mailing Address - Country:US
Mailing Address - Phone:480-889-9457
Mailing Address - Fax:480-696-5505
Practice Address - Street 1:500 N ESTRELLA PKWY
Practice Address - Street 2:SUITE B-1
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4135
Practice Address - Country:US
Practice Address - Phone:623-882-0782
Practice Address - Fax:623-882-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty