Provider Demographics
NPI:1477359818
Name:PROFESSIONAL DENTURES MOSES LAKE
Entity type:Organization
Organization Name:PROFESSIONAL DENTURES MOSES LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUNGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-885-5703
Mailing Address - Street 1:835 E COLONIAL AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4617
Mailing Address - Country:US
Mailing Address - Phone:509-707-0707
Mailing Address - Fax:
Practice Address - Street 1:835 E COLONIAL AVE STE 103
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4617
Practice Address - Country:US
Practice Address - Phone:509-707-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty