Provider Demographics
NPI:1376762468
Name:STAFFORD, GARY BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRIAN
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7128
Mailing Address - Country:US
Mailing Address - Phone:734-722-2180
Mailing Address - Fax:
Practice Address - Street 1:6149 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-7128
Practice Address - Country:US
Practice Address - Phone:734-722-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53151375481223G0001X
MI29010138271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice