Provider Demographics
NPI:1720670938
Name:SCOTTSDALE SKIN BOUTIQUE AESTHETICS
Entity Type:Organization
Organization Name:SCOTTSDALE SKIN BOUTIQUE AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:EGNATIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-998-1400
Mailing Address - Street 1:11333 N SCOTTSDALE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5186
Mailing Address - Country:US
Mailing Address - Phone:480-998-1400
Mailing Address - Fax:
Practice Address - Street 1:11333 N SCOTTSDALE RD STE 115
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5186
Practice Address - Country:US
Practice Address - Phone:480-998-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty