Provider Demographics
NPI:1447814199
Name:COPPER CANYON FAMILY DENTAL
Entity type:Organization
Organization Name:COPPER CANYON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-688-7348
Mailing Address - Street 1:PO BOX 5682
Mailing Address - Street 2:
Mailing Address - City:LK MONTEZUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:86342-5682
Mailing Address - Country:US
Mailing Address - Phone:480-688-7348
Mailing Address - Fax:
Practice Address - Street 1:26 W SALT MINE RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7170
Practice Address - Country:US
Practice Address - Phone:480-734-9784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty