MEDICARE: JOSE MOYA CRDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH26624	FL

General Provider Information

NPI Number	:	1588269625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE MOYA CRDH

Provider Business Mailing Address
First Line	:	2119 DELIGHTFUL DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33570-5825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2803 JAMES L REDMAN PKWY STE 1
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33566-9413
Country	:	US
Telephone Number	:	813-567-7151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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