Provider Demographics
NPI:1689353302
Name:DEGRAFFENRIED, DALLIN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DALLIN
Middle Name:A
Last Name:DEGRAFFENRIED
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1919
Mailing Address - Country:US
Mailing Address - Phone:435-979-0351
Mailing Address - Fax:
Practice Address - Street 1:1339 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1919
Practice Address - Country:US
Practice Address - Phone:435-979-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD118421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice