Provider Demographics
NPI:1376820597
Name:DUFFY C. DE GRAW D.D.S. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DUFFY C. DE GRAW D.D.S. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DUFFY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DE GRAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-528-3000
Mailing Address - Street 1:2238 BAYVIEW HEIGHTS DR STE F
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3932
Mailing Address - Country:US
Mailing Address - Phone:805-528-3000
Mailing Address - Fax:805-528-3080
Practice Address - Street 1:2238 BAYVIEW HEIGHTS DR STE F
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3932
Practice Address - Country:US
Practice Address - Phone:805-528-3000
Practice Address - Fax:805-528-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA572621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty