Provider Demographics
NPI:1164407870
Name:DHHS-PHS, IHS TUCSON AREA, IHS TUCSON SANTA ROSA CLINIC
Entity Type:Organization
Organization Name:DHHS-PHS, IHS TUCSON AREA, IHS TUCSON SANTA ROSA CLINIC
Other - Org Name:SANTA ROSA DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING AND BUDGET OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIESSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MBA, CPM
Authorized Official - Phone:520-295-2427
Mailing Address - Street 1:7900 S J STOCK RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-7012
Mailing Address - Country:US
Mailing Address - Phone:520-295-2427
Mailing Address - Fax:520-295-2611
Practice Address - Street 1:FEDERAL ROUTE 15
Practice Address - Street 2:
Practice Address - City:SANTA ROSA VILLAGE
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-383-5570
Practice Address - Fax:520-383-5572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Not Answered126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1770581639OtherFACILITY PROVIDER #
AZ147141-03Medicaid
AZAZ0209590OtherBC/BSAZ DENTAL PROV NO
AZ1073502506OtherPHARMACY PROV NO
AZ0327177OtherNACADP#
AZAZ0209630OtherBC/BSAZ PROV NO
AZAZ0209630OtherBC/BSAZ PROV NO
AZ1073502506OtherPHARMACY PROV NO