Provider Demographics
NPI:1639720980
Name:STAFFON, TERA
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:STAFFON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:
Other - Last Name:GILBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74 ECLIPSE CTR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3550
Mailing Address - Country:US
Mailing Address - Phone:608-361-0311
Mailing Address - Fax:
Practice Address - Street 1:74 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-361-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10345-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist