Provider Demographics
NPI:1245098391
Name:UPPER MATTAPONI INDIAN TRIBE
Entity type:Organization
Organization Name:UPPER MATTAPONI INDIAN TRIBE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR-UMIT HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUPPONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-347-4109
Mailing Address - Street 1:13476 KING WILLIAM RD
Mailing Address - Street 2:
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-3401
Mailing Address - Country:US
Mailing Address - Phone:804-769-0041
Mailing Address - Fax:
Practice Address - Street 1:8014 RICHMOND TAPPAHANNOCK HWY
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3056
Practice Address - Country:US
Practice Address - Phone:804-769-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UPPER MATTAPONI INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-12
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty