Provider Demographics
NPI:1538383591
Name:CANYON VIEW DENTAL PC
Entity type:Organization
Organization Name:CANYON VIEW DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LAURA
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-375-1192
Mailing Address - Street 1:710 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2134
Mailing Address - Country:US
Mailing Address - Phone:406-375-1192
Mailing Address - Fax:406-375-1193
Practice Address - Street 1:710 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2134
Practice Address - Country:US
Practice Address - Phone:406-375-1192
Practice Address - Fax:406-375-1193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21411223G0001X
MT21421223G0001X
MT749124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Single Specialty