Provider Demographics
NPI:1457630279
Name:FORT MOJAVE INDIAN TRIBE
Entity Type:Organization
Organization Name:FORT MOJAVE INDIAN TRIBE
Other - Org Name:FORT MOJAVE INDIAN HEALTH CENTER DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-629-4591
Mailing Address - Street 1:1607 PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-8420
Mailing Address - Country:US
Mailing Address - Phone:928-346-4679
Mailing Address - Fax:928-346-4686
Practice Address - Street 1:1607 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:MOHAVE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86440-8420
Practice Address - Country:US
Practice Address - Phone:928-346-4679
Practice Address - Fax:928-346-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental