Provider Demographics
NPI:1396314704
Name:THOMAS, STAFFORD (DMD)
Entity type:Individual
Prefix:
First Name:STAFFORD
Middle Name:
Last Name:THOMAS
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 1:8205 GRANDEUR DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-1634
Mailing Address - Country:US
Mailing Address - Phone:801-995-8645
Mailing Address - Fax:
Practice Address - Street 1:336 E HANES MILL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9135
Practice Address - Country:US
Practice Address - Phone:336-450-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12269OtherNORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS