Provider Demographics
NPI:1093004467
Name:SCOTT GORDEN STAFFORD, DDS, PC
Entity Type:Organization
Organization Name:SCOTT GORDEN STAFFORD, DDS, PC
Other - Org Name:STAFFORD FAMILY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-599-9610
Mailing Address - Street 1:12501 JUDSON RD
Mailing Address - Street 2:SUITE101
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4103
Mailing Address - Country:US
Mailing Address - Phone:210-599-9610
Mailing Address - Fax:210-946-8119
Practice Address - Street 1:12501 JUDSON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-4103
Practice Address - Country:US
Practice Address - Phone:210-599-9610
Practice Address - Fax:210-946-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18592122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty