=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639466824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAFE ALLEN CHAFFEE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2011
-----------------------------------------------------
Last Update Date | 06/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 N MISSION PKWY
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85194-8412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-426-3639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 N MISSION PKWY
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85194-8412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-426-3639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 995
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D008634
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------