Basic Information
| Provider Information | |||||||||
| NPI: | 1992819858 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PIMC DENTAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-0698 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911100698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Practice Location | |||||||||
| Address1: | 4212 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022631200 | ||||||||
| FaxNumber: | 6022631618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICK | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | (CEO) CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6022631567 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW., MHA. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 124Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 126800000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Assistant | 1223D0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0700X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 022062 | 05 | AZ | MEDICAID | P0206550 | 01 | AZ | BCBSAZ | OTHER | 092354 | 05 | AZ | MEDICAID | 418196 | 05 | AZ | MEDICAID |