=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164407870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHHS-PHS, IHS TUCSON AREA, IHS TUCSON SANTA ROSA CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2005
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | FEDERAL ROUTE 15
-----------------------------------------------------
City | SANTA ROSA VILLAGE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-383-5570
-----------------------------------------------------
Fax | 520-383-5572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7900 S J STOCK RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85746-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-295-2427
-----------------------------------------------------
Fax | 520-295-2611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTING AND BUDGET OFFICER
-----------------------------------------------------
Name | MR. KURT PRIESSMAN
-----------------------------------------------------
Credential | M.A., M.B.A., C.P.M.
-----------------------------------------------------
Telephone | 520-295-2427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------