Healthcare Provider Details

I. General information

NPI: 1548773385
Provider Name (Legal Business Name): JOSEPH FARAYI MOYOSVIYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 6TH ST
CLARKSTON WA
99403-2013
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 208-848-8300
  • Fax: 509-444-7806
Mailing address:
  • Phone: 509-444-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberIL60704501
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH6068736
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: