Organization Name: | STATEWIDE DENTURE SERVICES |
NPI Number: | 1154743813 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JOSHUA D BROOKS (OWNER/SOLE MEMBER) |
Mailing Address: | 1225 Meade Ave Prosser |
State: | WA US |
Postal Code: | 993501423 |
Phone Number: | 5095864350 |
Fax Number: | 8886569322 |
NPI Enumeration Date: | 01/15/2014 |
NPI Last Update Date: | 01/15/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 122400000X |
License Number: | DB00000391 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WA |
Taxonomy Type: | Dental Providers |
Taxonomy Classification: | Denturist |
Taxonomy Specialization: | |
Taxonomy Definition: |