Basic Information
| Provider Information | |||||||||
| NPI: | 1447420591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINSLOW INDIAN HEALTH CARE CTR DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860470400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9282896291 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860472169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9282896291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF DENTAL | ||||||||
| AuthorizedOfficialTelephone: | 9282894646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WINSLOW INDIAN HEALTH CARE CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 758518 | 05 | AZ | MEDICAID |