Provider Demographics
NPI:1194048744
Name:CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP
Entity type:Organization
Organization Name:CANYON VISTA DENTISTRY AND ORTHODONTICS,LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:R
Authorized Official - Last Name:COCKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-561-6767
Mailing Address - Street 1:2860 MICHELLE FL 2
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1008
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:
Practice Address - Street 1:25155 N 67TH AVE STE 142
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-1065
Practice Address - Country:US
Practice Address - Phone:626-561-6767
Practice Address - Fax:623-561-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty