Provider Demographics
NPI:1578618831
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other - Org Name:YAHC DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-263-1674
Mailing Address - Street 1:PO BOX 95460
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-0033
Mailing Address - Country:US
Mailing Address - Phone:602-581-6088
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:2121 WEST RESERVATION LOOP ROAD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-8412
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ812869Medicaid
AZ030078Medicare Oscar/Certification
AZTEZ084Medicare ID - Type UnspecifiedPART B