Provider Demographics
NPI:1215078712
Name:SIU, TREVER L (DMD, MS)
Entity type:Individual
Prefix:
First Name:TREVER
Middle Name:L
Last Name:SIU
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2767 E PALMER ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-5749
Mailing Address - Country:US
Mailing Address - Phone:480-895-0801
Mailing Address - Fax:
Practice Address - Street 1:13065 W MCDOWELL RD
Practice Address - Street 2:SUITE A101
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6439
Practice Address - Country:US
Practice Address - Phone:623-935-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ68411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics