Provider Demographics
NPI:1710085907
Name:STAFFORD, GREGORY L (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
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 1:623 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-4201
Mailing Address - Country:US
Mailing Address - Phone:501-374-2929
Mailing Address - Fax:501-374-8611
Practice Address - Street 1:623 MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-4201
Practice Address - Country:US
Practice Address - Phone:501-374-2929
Practice Address - Fax:501-374-6811
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158205608Medicaid