=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649432121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHHS PHS IHS PHOENIX AREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2008
-----------------------------------------------------
Last Update Date | 04/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 PICACHO ROAD
-----------------------------------------------------
City | WINTERHAVEN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-572-4100
-----------------------------------------------------
Fax | 760-572-2133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1368
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-572-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICE
-----------------------------------------------------
Name | CINDY S BALDWIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-572-4100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------