Provider Demographics
NPI:1932274214
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:SALT RIVER DENTAL
Other - Org Type:Doing Business As
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:602-263-1200
Mailing Address - Fax:602-263-1618
Practice Address - Street 1:10005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
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:2006-11-21
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092353Medicaid
AZP0109880OtherBCBSAZ
AZG=========OtherBCBSAZ
AZ092353Medicaid
AZP0109880OtherBCBSAZ