Healthcare Provider Details

I. General information

NPI: 1336275833
Provider Name (Legal Business Name): ARIZONA DEPARTMENT OF HEALTH SERVICES, OFFICE OF ORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W ADAMS ST RM 205
PHOENIX AZ
85007-2607
US

IV. Provider business mailing address

1740 W ADAMS ST RM 205
PHOENIX AZ
85007-2607
US

V. Phone/Fax

Practice location:
  • Phone: 602-542-1866
  • Fax: 602-542-2936
Mailing address:
  • Phone: 602-542-1866
  • Fax: 602-542-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateAZ

VIII. Authorized Official

Name: MS. PATRICIA A. PRICE
Title or Position: SEALANT PROGRAM MANAGER
Credential: BSDH, MED
Phone: 602-542-1891