Provider Demographics
NPI:1811487234
Name:STAFFORD, NATALIE JO
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:JO
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11801 W WOODLAND CIR
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1075
Mailing Address - Country:US
Mailing Address - Phone:414-732-8628
Mailing Address - Fax:
Practice Address - Street 1:10155 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1645
Practice Address - Country:US
Practice Address - Phone:262-844-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10018171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice