Provider Demographics
NPI:1255695813
Name:ADVANCED DENTAL GROUP, INC.
Entity type:Organization
Organization Name:ADVANCED DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SPILOTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-680-9911
Mailing Address - Street 1:7217 W CAMINO DE ORO
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3266
Mailing Address - Country:US
Mailing Address - Phone:602-504-6400
Mailing Address - Fax:602-504-6300
Practice Address - Street 1:15440 N 7TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3535
Practice Address - Country:US
Practice Address - Phone:602-504-6400
Practice Address - Fax:602-504-6300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4664122300000X
AZD59151223E0200X
AZD5123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ835324Medicaid
AZ633679Medicaid
AZ639651Medicaid
AZ996431OtherUNITED CONCORDIA
AZAZ0414080OtherBLUE CROSS BLUE SHIELD OF AZ