Provider Demographics
NPI:1295096253
Name:STAFFORD, MATHEW (DDS)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
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 1:151 LE GORDON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4333
Mailing Address - Country:US
Mailing Address - Phone:804-379-9177
Mailing Address - Fax:
Practice Address - Street 1:151 LE GORDON DR STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4333
Practice Address - Country:US
Practice Address - Phone:804-379-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist