Provider Demographics
NPI:1326122995
Name:DAMRON, STAFFORD RUSSELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:STAFFORD
Middle Name:RUSSELL
Last Name:DAMRON
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 1:335 YORK ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-4901
Mailing Address - Country:US
Mailing Address - Phone:859-261-6116
Mailing Address - Fax:859-261-7074
Practice Address - Street 1:335 YORK ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-4901
Practice Address - Country:US
Practice Address - Phone:859-261-6116
Practice Address - Fax:859-261-7074
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60068574Medicaid