Provider Demographics
NPI:1730341215
Name:DHEW IND HLTH SVCS & MNTL HLTH SVCS
Entity type:Organization
Organization Name:DHEW IND HLTH SVCS & MNTL HLTH SVCS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-725-6874
Mailing Address - Street 1:6822 E. 1000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-722-5122
Mailing Address - Fax:
Practice Address - Street 1:6822 E 1000 SOUTH
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-722-5122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0522260OtherBLUE CROSS BLUE SHIELD
UT700000000009Medicaid
AZAZ0522260OtherBLUE CROSS BLUE SHIELD
UT700000000009Medicaid