1780730549 NPI number — DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.

Table of content: (NPI 1780730549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780730549 NPI number — DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GILA BEND CLINIC DENTAL SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780730549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-0698
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-0698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-263-1511
Provider Business Mailing Address Fax Number:
602-263-1619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NORTH GILA BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILA BEND
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85227-2658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-263-1511
Provider Business Practice Location Address Fax Number:
602-263-1619
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DICK
Authorized Official First Name:
DEANNA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
(CEO) CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
602-263-1567

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223D0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 124Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 126800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 812851 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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