Healthcare Provider Details

I. General information

NPI: 1689365777
Provider Name (Legal Business Name): MOURA GHATTAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9329 27TH AVE SE
EVERETT WA
98208-3608
US

IV. Provider business mailing address

9329 27TH AVE SE
EVERETT WA
98208-3608
US

V. Phone/Fax

Practice location:
  • Phone: 425-368-8904
  • Fax:
Mailing address:
  • Phone: 425-368-8904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number70127681
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: