Provider Demographics
NPI:1780139931
Name:THE PROFESSIONAL DENTURE CENTER
Entity type:Organization
Organization Name:THE PROFESSIONAL DENTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:509-664-7308
Mailing Address - Street 1:533 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3047
Mailing Address - Country:US
Mailing Address - Phone:509-664-7308
Mailing Address - Fax:509-664-4068
Practice Address - Street 1:533 S MISSION ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3047
Practice Address - Country:US
Practice Address - Phone:509-664-7308
Practice Address - Fax:509-664-4068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60292621292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2059589Medicaid