| Organization Name: | MOUNTAIN LAKE DENTURE SERVICES, PLLC |
| NPI Number: | 1962715805 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOSHUA D BROOKS (MEMBER) |
| Mailing Address: | 1225 Meade Ave Prosser |
| State: | WA US |
| Postal Code: | 993501423 |
| Phone Number: | 5097862963 |
| Fax Number: | 8886569322 |
| NPI Enumeration Date: | 07/21/2010 |
| NPI Last Update Date: | 07/21/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 122400000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Denturist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |