Provider Demographics
NPI:1306576749
Name:BLACK CANYON DENTAL, P.C.
Entity type:Organization
Organization Name:BLACK CANYON DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDOSO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-471-3690
Mailing Address - Street 1:3815 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7546
Mailing Address - Country:US
Mailing Address - Phone:801-471-3690
Mailing Address - Fax:
Practice Address - Street 1:1544 OXBOW DR STE 230
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5189
Practice Address - Country:US
Practice Address - Phone:801-471-3690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty