Healthcare Provider Details

I. General information

NPI: 1144347501
Provider Name (Legal Business Name): DHHS IHS PHOENIX AREA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL WAY
WHITERIVER AZ
85941-0860
US

IV. Provider business mailing address

PO BOX 860 200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941-0860
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-4911
  • Fax: 928-338-5508
Mailing address:
  • Phone: 928-338-4911
  • Fax: 928-338-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE MARTINEZ
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: FNP
Phone: 928-338-4911