Provider Demographics
NPI:1285842674
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 - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:GORDEN
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:830-980-3381
Mailing Address - Street 1:13414 LA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2205
Mailing Address - Country:US
Mailing Address - Phone:830-980-3381
Mailing Address - Fax:
Practice Address - Street 1:30695 NORTH HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163
Practice Address - Country:US
Practice Address - Phone:830-980-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX185921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty