MEDICARE: GARY CHAFFEE DDS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	25371	CA

General Provider Information

NPI Number	:	1750402889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY CHAFFEE DDS, INC.

Provider Business Mailing Address
First Line	:	350 VIA LAS BRISAS
Second Line	:	SUITE 210
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-7034
Country	:	US
Telephone Number	:	805-480-0033
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 VIA LAS BRISAS
Second Line	:	210
City	:	NEWBURY PARK
State	:	CA
Zip	:	91320-7034
Country	:	US
Telephone Number	:	805-480-0033
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GARY DUANE CHAFFEE
Credential	:	DDS
Telephone Number	:	805-480-0033

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	05/24/2012

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