Provider Demographics
NPI:1407255326
Name:MOSES, JESSE RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:RYAN
Last Name:MOSES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:RYAN
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:16600 SE 15TH STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:360-514-0055
Mailing Address - Fax:360-514-0095
Practice Address - Street 1:16600 SE 15TH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-514-0055
Practice Address - Fax:360-514-0095
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000092421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics