Provider Demographics
NPI:1043356058
Name:CANYON TRAILS DENTAL CARE, PC
Entity type:Organization
Organization Name:CANYON TRAILS DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DELWYN
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-882-0782
Mailing Address - Street 1:500 N ESTRELLA PKWY
Mailing Address - Street 2:SUITE B1
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4135
Mailing Address - Country:US
Mailing Address - Phone:623-882-0782
Mailing Address - Fax:
Practice Address - Street 1:500 N ESTRELLA PKWY
Practice Address - Street 2:SUITE B1
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4135
Practice Address - Country:US
Practice Address - Phone:623-882-0782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty