Provider Demographics
NPI:1457516155
Name:STAFFORD, MARK LAVERNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAVERNE
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 1:1460 7TH STREET
Mailing Address - Street 2:#205
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401
Mailing Address - Country:US
Mailing Address - Phone:310-393-8317
Mailing Address - Fax:310-458-8804
Practice Address - Street 1:1460 7TH STREET
Practice Address - Street 2:#205
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401
Practice Address - Country:US
Practice Address - Phone:310-393-8317
Practice Address - Fax:310-458-8804
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA289861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice