Provider Demographics
NPI:1437791548
Name:THE DENTAL BOUTIQUE PLLC
Entity Type:Organization
Organization Name:THE DENTAL BOUTIQUE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-531-3631
Mailing Address - Street 1:2128 W TALLGRASS TRL UNIT 216
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0743
Mailing Address - Country:US
Mailing Address - Phone:480-531-3631
Mailing Address - Fax:
Practice Address - Street 1:8075 E MORGAN TRL STE 3
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1213
Practice Address - Country:US
Practice Address - Phone:480-531-3631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty