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General NPI Number Information
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NPI Number | 1962916379
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Entity Type | Organization
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Legal Business Name | THE PROFESSIONAL DENTURE CENTER
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Dates
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Enumeration Date | 11/21/2017
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Last Update Date | 03/17/2025
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Provider Practice Location Address
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Address Line | 835 E COLONIAL AVE STE 103
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City | MOSES LAKE
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State | WA
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Zip | 98837-4617
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Country | US
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Telephone | 509-707-0707
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Fax |
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Provider Business Mailing Address
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Address Line | 835 E COLONIAL AVE STE 103
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City | MOSES LAKE
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State | WA
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Zip | 98837-4617
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Country | US
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Telephone | 509-707-0707
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Fax |
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. JONATHAN MUNGER DICKSON
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Credential | DMD
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Telephone | 253-230-8084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | 60772847
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 60292621
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License Number State | WA
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