=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922346774
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DREW KEVIN ADDY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2013
-----------------------------------------------------
Last Update Date | 10/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1184 W 30TH ST APARTMENT #8
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-3183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-925-0210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2879 HOPE AVE
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-729-5881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 64006
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------