Provider Demographics
NPI:1780730549
Name:DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.
Entity type:Organization
Organization Name:DHEW INDIAN HEALTH SERVICE HEALTH SERVICES & MENTAL HEALTH ADM.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:(CEO) CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MHA
Authorized Official - Phone:602-263-1567
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1511
Mailing Address - Fax:602-263-1619
Practice Address - Street 1:100 NORTH GILA BOULEVARD
Practice Address - Street 2:
Practice Address - City:GILA BEND
Practice Address - State:AZ
Practice Address - Zip Code:85227-2658
Practice Address - Country:US
Practice Address - Phone:602-263-1511
Practice Address - Fax:602-263-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ812851Medicaid
AZHSZ195Medicare ID - Type UnspecifiedPART B
AZ812851Medicaid