Healthcare Provider Details

I. General information

NPI: 1972748747
Provider Name (Legal Business Name): DEREK JAY GRAFF D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 N BUTLER AVE STE 200
FARMINGTON NM
87401-2336
US

IV. Provider business mailing address

3180 N BUTLER AVE STE 200
FARMINGTON NM
87401-2336
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4884
  • Fax: 505-327-9089
Mailing address:
  • Phone: 505-327-4884
  • Fax: 505-327-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3086
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: