Healthcare Provider Details

I. General information

NPI: 1124567995
Provider Name (Legal Business Name): FORT MCDERMITT TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NO RESERVATION ROAD
MCDERMITT NV
89421-0315
US

IV. Provider business mailing address

112 NO RESERVATION ROAD
MCDERMITT NV
89421-0315
US

V. Phone/Fax

Practice location:
  • Phone: 775-532-8522
  • Fax: 775-532-8024
Mailing address:
  • Phone: 775-532-8522
  • Fax: 775-532-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: VALERIE BARR
Title or Position: CFO
Credential:
Phone: 775-532-8259