Provider Demographics
NPI:1124046842
Name:CONSOLIDATED TRIBAL HEALTH PROJECT INC
Entity Type:Organization
Organization Name:CONSOLIDATED TRIBAL HEALTH PROJECT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:NMN
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-485-5115
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:CALPELLA
Mailing Address - State:CA
Mailing Address - Zip Code:95418-0387
Mailing Address - Country:US
Mailing Address - Phone:707-485-5115
Mailing Address - Fax:
Practice Address - Street 1:6991 N STATE ST
Practice Address - Street 2:
Practice Address - City:REDWOOD VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95470-9629
Practice Address - Country:US
Practice Address - Phone:707-485-5115
Practice Address - Fax:707-485-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA195691223G0001X
WI50004591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty