Provider Demographics
NPI:1003776097
Name:CANON KIDS DENTAL & BRACES, PC
Entity type:Organization
Organization Name:CANON KIDS DENTAL & BRACES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RCM
Authorized Official - Prefix:
Authorized Official - First Name:ENJOLI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUILLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-464-0753
Mailing Address - Street 1:2041 PEPPER LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3276
Mailing Address - Country:US
Mailing Address - Phone:719-285-0994
Mailing Address - Fax:719-285-0996
Practice Address - Street 1:1201 ROYAL GORGE BLVD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3835
Practice Address - Country:US
Practice Address - Phone:719-285-0994
Practice Address - Fax:719-285-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty