Provider Demographics
NPI:1780729475
Name:GREGORY W STAFFON DDS A DENTAL CORPORATION
Entity type:Organization
Organization Name:GREGORY W STAFFON DDS A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:STAFFON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-434-3103
Mailing Address - Street 1:PO BOX 6187
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-6187
Mailing Address - Country:US
Mailing Address - Phone:949-280-9871
Mailing Address - Fax:760-434-3107
Practice Address - Street 1:2815 JEFFERSON ST STE 300
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1717
Practice Address - Country:US
Practice Address - Phone:760-434-3103
Practice Address - Fax:760-434-3108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty