Basic Information
| Provider Information | |||||||||
| NPI: | 1366848897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYON MODERN DENTISTRY & ORTHODONTICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17081 W GREENWAY RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853889612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235468400 | ||||||||
| FaxNumber: | 6232145830 | ||||||||
| Practice Location | |||||||||
| Address1: | 17081 W GREENWAY RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853889612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235468400 | ||||||||
| FaxNumber: | 6232145830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | KHAKWANI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMED | ||||||||
| AuthorizedOfficialMiddleName: | REZA | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 3167276886 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | D009075 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.