Organization
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM.
Active
Parent organization
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other names
IHS PHX MED CTR-DENTAL, PIMC Dental Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Authorized official
DR. LAURA TILLMAN MD (CHIEF MEDICAL OFFICER)
(602) 263-1674
Entity
Organization
Contact information
Practice address
4212 N 16TH ST, PHOENIX, AZ 85016-5319
(602) 263-1200
(602) 263-1619
Mailing address
PO BOX 95460, CLEVELAND, OH 44101-0033
(602) 581-6076
(602) 263-1619
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
1223D0001X
Public Health Dentistry
—
—
1223E0200X
Endodontics
—
—
1223G0001X
General Practice Dentistry
—
—
1223P0221X
Pediatric Dentistry
—
—
1223P0300X
Periodontics
—
—
1223P0700X
Prosthodontics
—
—
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
—
—
124Q00000X
Dental Hygienist
—
—
126800000X
Dental Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
022062
—
AZ
05
—
092354
—
AZ
05
—
418196
—
AZ
01
—
P0206550
BCBSAZ
AZ
Enumeration date
08/18/2006
Last updated
07/01/2026
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