Provider Demographics
NPI:1891902003
Name:CANYON HILLS FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:CANYON HILLS FAMILY DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-917-0181
Mailing Address - Street 1:602 W UNION HILLS DR
Mailing Address - Street 2:SUITE #8
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-6629
Mailing Address - Country:US
Mailing Address - Phone:623-516-7766
Mailing Address - Fax:623-516-7788
Practice Address - Street 1:602 W UNION HILLS DR
Practice Address - Street 2:SUITE #8
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-6629
Practice Address - Country:US
Practice Address - Phone:623-516-7766
Practice Address - Fax:623-516-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1778674OtherUCCI
AZ004Medicare ID - Type UnspecifiedMERCY CARE
AZ1778674OtherUCCI