Healthcare Provider Details

I. General information

NPI: 1396751475
Provider Name (Legal Business Name): GREGORY PEARY STAFFORD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 NE GLISAN ST
PORTLAND OR
97220-4456
US

IV. Provider business mailing address

6325 SW ELM AVE
BEAVERTON OR
97005-4218
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-5959
  • Fax: 503-408-1472
Mailing address:
  • Phone: 503-626-7826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD6558
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEOOOO6891
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: