Provider Demographics
NPI:1134754187
Name:CONROTTO, TJISKA ELAINE (DDS)
Entity type:Individual
Prefix:DR
First Name:TJISKA
Middle Name:ELAINE
Last Name:CONROTTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E MCDOWELL RD APT 2014
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1680
Mailing Address - Country:US
Mailing Address - Phone:209-872-5274
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST # 2014
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:209-872-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1047301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice