=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376820597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUFFY C. DE GRAW D.D.S. A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2011
-----------------------------------------------------
Last Update Date | 11/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2238 BAYVIEW HEIGHTS DR STE F
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-528-3000
-----------------------------------------------------
Fax | 805-528-3080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2238 BAYVIEW HEIGHTS DR STE F
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-528-3000
-----------------------------------------------------
Fax | 805-528-3080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. DUFFY CHARLES DE GRAW
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 805-528-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 57262
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------