Provider Demographics
NPI:1215082839
Name:STAFFORD, GARY L (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W WISCONSIN AVE
Mailing Address - Street 2:RM 336A
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2186
Mailing Address - Country:US
Mailing Address - Phone:414-288-5409
Mailing Address - Fax:
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:RM 336A
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-5409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice