Provider Demographics
NPI:1508319237
Name:TOHONO O'ODHAM NATION
Entity Type:Organization
Organization Name:TOHONO O'ODHAM NATION
Other - Org Name:TON SAN SIMON HEALTH CENTER DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-383-2028
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:SELLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85634-0810
Mailing Address - Country:US
Mailing Address - Phone:520-383-7200
Mailing Address - Fax:520-383-3930
Practice Address - Street 1:HIGHWAY 86, MILE MARKER 74
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-362-7003
Practice Address - Fax:520-383-7009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOHONO O'ODHAM NATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ122300000X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030074Medicare Oscar/Certification