Healthcare Provider Details

I. General information

NPI: 1497487318
Provider Name (Legal Business Name): DILLON Z MOYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5071 NE 122ND AVE
PORTLAND OR
97230-1003
US

IV. Provider business mailing address

3850 S BOND AVE APT 436
PORTLAND OR
97239-4836
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-5700
  • Fax:
Mailing address:
  • Phone: 915-345-5387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number38504
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38504
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11762
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: