Provider Demographics
NPI:1649403775
Name:PTACEK, TINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:PTACEK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23219 N DEL MONTE DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-2372
Mailing Address - Country:US
Mailing Address - Phone:623-628-6858
Mailing Address - Fax:
Practice Address - Street 1:15180 N COTTON LN STE 104
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-7000
Practice Address - Country:US
Practice Address - Phone:623-214-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX324911223P0221X
AZD78181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry