Provider Demographics
NPI:1639635709
Name:SPECIALTY DENTURE SERVICE INC
Entity Type:Organization
Organization Name:SPECIALTY DENTURE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED DENTURIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:NEURENE
Authorized Official - Last Name:PECHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-999-0615
Mailing Address - Street 1:12501 S KEENEY RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-9205
Mailing Address - Country:US
Mailing Address - Phone:509-999-0615
Mailing Address - Fax:
Practice Address - Street 1:12501 S KEENEY RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-9205
Practice Address - Country:US
Practice Address - Phone:509-999-0615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1063577245Medicaid