Provider Demographics
NPI:1124549191
Name:PLATINUM DENTAL SPA PLLC
Entity Type:Organization
Organization Name:PLATINUM DENTAL SPA PLLC
Other - Org Name:MODERN DENTISTRY OF SUNCITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOTAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-977-2551
Mailing Address - Street 1:13660 N 94TH DR STE B1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4848
Mailing Address - Country:US
Mailing Address - Phone:623-977-2551
Mailing Address - Fax:
Practice Address - Street 1:13660 N 94TH DR STE B1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4848
Practice Address - Country:US
Practice Address - Phone:623-977-2551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental