Provider Demographics
NPI:1104497403
Name:FAGHIH, JASON M (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:FAGHIH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3002
Mailing Address - Country:US
Mailing Address - Phone:206-250-9991
Mailing Address - Fax:
Practice Address - Street 1:217 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3002
Practice Address - Country:US
Practice Address - Phone:509-525-7250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1061881223G0001X
WADE61171187122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty