Healthcare Provider Details

I. General information

NPI: 1962916379
Provider Name (Legal Business Name): THE PROFESSIONAL DENTURE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E COLONIAL AVE STE 103
MOSES LAKE WA
98837-4617
US

IV. Provider business mailing address

835 E COLONIAL AVE STE 103
MOSES LAKE WA
98837-4617
US

V. Phone/Fax

Practice location:
  • Phone: 509-707-0707
  • Fax:
Mailing address:
  • Phone: 509-707-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number60292621
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number60772847
License Number StateWA

VIII. Authorized Official

Name: DR. JONATHAN MUNGER DICKSON
Title or Position: DOCTOR/OWNER
Credential: DMD
Phone: 253-230-8084