Organization
CANYON RIVER DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RYAN T MANGRUM DMD (DENTIST)
(801) 221-5859
Entity
Organization
Contact information
Practice address
3707 N CANYON RD, SUITE 7D, PROVO, UT 84604
(801) 221-5859
(801) 221-7091
Mailing address
3707 N CANYON RD, SUITE 7D, PROVO, UT 84604
(801) 221-5859
(801) 221-7091
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
3124349922
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
529578391004
—
UT
Enumeration date
09/20/2006
Last updated
08/22/2020
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