Healthcare Provider Details

I. General information

NPI: 1780730549
Provider Name (Legal Business Name): DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH GILA BOULEVARD
GILA BEND AZ
85227-2658
US

IV. Provider business mailing address

PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1619
Mailing address:
  • Phone: 602-263-1511
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MISS DEANNA J. DICK
Title or Position: (CEO) CHIEF EXECUTIVE OFFICER
Credential: MSW., MHA.
Phone: 602-263-1567