Provider Demographics
NPI:1962715805
Name:MOUNTAIN LAKE DENTURE SERVICES, PLLC
Entity type:Organization
Organization Name:MOUNTAIN LAKE DENTURE SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPD
Authorized Official - Phone:509-303-9090
Mailing Address - Street 1:1225 MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1423
Mailing Address - Country:US
Mailing Address - Phone:509-786-2963
Mailing Address - Fax:888-656-9322
Practice Address - Street 1:1225 MEADE AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1423
Practice Address - Country:US
Practice Address - Phone:509-786-2963
Practice Address - Fax:888-656-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty