Provider Demographics
NPI:1144347501
Name:DHHS IHS PHOENIX AREA
Entity type:Organization
Organization Name:DHHS IHS PHOENIX AREA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-338-4911
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:200 WEST HOSPITAL DRIVE
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 WEST HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-5508
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS IHS PHOENIX AREA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020561Medicaid
AZ092403-01Medicaid
AZAZ0109760OtherBC DENTAL