Provider Demographics
NPI:1871683359
Name:MOFFITT, JASON RUSK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RUSK
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S COWLEY ST.
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1395
Mailing Address - Country:US
Mailing Address - Phone:509-838-1445
Mailing Address - Fax:509-455-8955
Practice Address - Street 1:520 S COWLEY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1315
Practice Address - Country:US
Practice Address - Phone:509-838-1445
Practice Address - Fax:509-455-8955
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025103DE000079481223P0221X
WADH00001904124Q00000X
126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered124Q00000XDental ProvidersDental Hygienist
Not Answered126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5036652Medicaid