Provider Demographics
NPI:1457732588
Name:STAFFORD DENTAL PC
Entity Type:Organization
Organization Name:STAFFORD DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-221-6700
Mailing Address - Street 1:300 N AIRPORT RD
Mailing Address - Street 2:STE 1
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35504-2517
Mailing Address - Country:US
Mailing Address - Phone:205-221-6700
Mailing Address - Fax:205-221-9194
Practice Address - Street 1:300 N AIRPORT RD
Practice Address - Street 2:STE 1
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35504-2517
Practice Address - Country:US
Practice Address - Phone:205-221-6700
Practice Address - Fax:205-221-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL37881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty