Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D9884 | OR |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DE 60360644 | WA |
NPI | 1043530173 |
---|---|
Provider Name | Wayne Van De Graaff |
First Address | Tigard, OR 97224 |
Second Address | Brooklyn, NY 11209-7104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2010 |
Last Update Date | 19/03/2014 |