Provider Demographics
NPI:1104019660
Name:BELLE VISTA DENTURE CLINIC, PLLC
Entity Type:Organization
Organization Name:BELLE VISTA DENTURE CLINIC, PLLC
Other - Org Name:BELLA VISTA DENTURE CLINIC, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE 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:
Authorized Official - Phone:509-786-2963
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 1:3609 W NOB HILL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4744
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:2007-08-19
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049218Medicaid