MEDICARE: RAUL D PEREZ 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	61046	CA

General Provider Information

NPI Number	:	1760903678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAUL D PEREZ DDS, INC.

Provider Business Mailing Address
First Line	:	1163 W GRAND AVE
Second Line	:
City	:	GROVER BEACH
State	:	CA
Zip	:	93433-2149
Country	:	US
Telephone Number	:	805-904-6979
Fax Number	:	805-904-6989

Provider Business Practice Location Address
First Line	:	1163 W GRAND AVE
Second Line	:
City	:	GROVER BEACH
State	:	CA
Zip	:	93433-2149
Country	:	US
Telephone Number	:	805-904-6979
Fax Number	:	805-904-6979

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RAUL DARIO PEREZ
Credential	:	DDS
Telephone Number	:	805-904-6979

Provider Enumeration Date	:	06/30/2017
Last Update Date	:	06/16/2018

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