Provider Demographics
NPI:1588397897
Name:CANASTILLO, PRISCILLA (DMD)
Entity type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:CANASTILLO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:MADRIL
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:231 W THOMAS RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4406
Mailing Address - Country:US
Mailing Address - Phone:520-468-1991
Mailing Address - Fax:
Practice Address - Street 1:111 W MONROE ST STE 131
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1717
Practice Address - Country:US
Practice Address - Phone:602-626-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist