Healthcare Provider Details

I. General information

NPI: 1962642132
Provider Name (Legal Business Name): SUN LAKES PERIODONTICS & IMPLANT DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 E RIGGS RD SUITE #118
SUN LAKES AZ
85248-7758
US

IV. Provider business mailing address

10450 E RIGGS RD SUITE #118
SUN LAKES AZ
85248-7758
US

V. Phone/Fax

Practice location:
  • Phone: 480-895-0801
  • Fax: 480-895-5927
Mailing address:
  • Phone: 480-895-0801
  • Fax: 480-895-5927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6841
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. TREVER L SIU
Title or Position: DENTIST/OWNER
Credential: DMD, MS
Phone: 480-895-0801