Provider Demographics
NPI:1477917490
Name:MORENO, JANE ELIZABETH (RDH)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH
Last Name:MORENO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 ELM PL
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-4646
Mailing Address - Country:US
Mailing Address - Phone:206-954-3573
Mailing Address - Fax:
Practice Address - Street 1:23320 HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8744
Practice Address - Country:US
Practice Address - Phone:425-640-5533
Practice Address - Fax:425-640-5534
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00002649124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist