Provider Demographics
NPI:1962642132
Name:SUN LAKES PERIODONTICS & IMPLANT DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SUN LAKES PERIODONTICS & IMPLANT DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:480-895-0801
Mailing Address - Street 1:10450 E RIGGS RD
Mailing Address - Street 2:SUITE #118
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7758
Mailing Address - Country:US
Mailing Address - Phone:480-895-0801
Mailing Address - Fax:480-895-5927
Practice Address - Street 1:10450 E RIGGS RD
Practice Address - Street 2:SUITE #118
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7758
Practice Address - Country:US
Practice Address - Phone:480-895-0801
Practice Address - Fax:480-895-5927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ68411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty