Healthcare Provider Details

I. General information

NPI: 1902979669
Provider Name (Legal Business Name): J RYAN MOSES DMD PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 SE 15 ST STE 150
VANCOUVER WA
98683
US

IV. Provider business mailing address

16500 SE 15 ST STE 150
VANCOUVER WA
98683
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-0055
  • Fax: 360-514-0095
Mailing address:
  • Phone: 360-514-0055
  • Fax: 360-514-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE RYAN MOSES
Title or Position: PRESIDENT
Credential: DMD
Phone: 360-514-0055