Provider Demographics
NPI:1336275833
Name:ARIZONA DEPARTMENT OF HEALTH SERVICES, OFFICE OF ORAL HEALTH
Entity Type:Organization
Organization Name:ARIZONA DEPARTMENT OF HEALTH SERVICES, OFFICE OF ORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEALANT PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:BSDH, MED
Authorized Official - Phone:602-542-1891
Mailing Address - Street 1:1740 W ADAMS ST
Mailing Address - Street 2:RM 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-2607
Mailing Address - Country:US
Mailing Address - Phone:602-542-1866
Mailing Address - Fax:602-542-2936
Practice Address - Street 1:1740 W ADAMS ST
Practice Address - Street 2:RM 205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2607
Practice Address - Country:US
Practice Address - Phone:602-542-1866
Practice Address - Fax:602-542-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ703886Medicaid