Provider Demographics
NPI:1942657952
Name:MOSES LAKE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:MOSES LAKE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:HAMILTON
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PS
Authorized Official - Phone:509-765-2255
Mailing Address - Street 1:800 N STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1512
Mailing Address - Country:US
Mailing Address - Phone:509-765-2255
Mailing Address - Fax:509-765-1155
Practice Address - Street 1:800 N STRATFORD RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1512
Practice Address - Country:US
Practice Address - Phone:509-765-2255
Practice Address - Fax:509-765-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60331610122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050514Medicaid