Provider Demographics
NPI:1548506058
Name:CANYON GATE DENTAL CARE LLC
Entity type:Organization
Organization Name:CANYON GATE DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-764-9444
Mailing Address - Street 1:440 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3728
Mailing Address - Country:US
Mailing Address - Phone:801-764-9444
Mailing Address - Fax:
Practice Address - Street 1:440 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3728
Practice Address - Country:US
Practice Address - Phone:801-764-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2899691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty