Provider Demographics
NPI:1376771907
Name:GELFOND, STANISLAV (DDS)
Entity Type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:GELFOND
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 1:3601 W BROADWAY APT 31-103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-0398
Mailing Address - Country:US
Mailing Address - Phone:515-490-0758
Mailing Address - Fax:
Practice Address - Street 1:2012 CHERRY HILL DR STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5882
Practice Address - Country:US
Practice Address - Phone:573-446-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090152841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice