Provider Demographics
NPI:1609194604
Name:STAFFORD FAMILY DENTIST
Entity type:Organization
Organization Name:STAFFORD FAMILY DENTIST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:GORAVANCHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-564-0117
Mailing Address - Street 1:11753 W BELLFORT ST
Mailing Address - Street 2:116
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-1327
Mailing Address - Country:US
Mailing Address - Phone:281-564-0117
Mailing Address - Fax:281-564-0132
Practice Address - Street 1:11753 W BELLFORT ST
Practice Address - Street 2:116
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-1327
Practice Address - Country:US
Practice Address - Phone:281-564-0117
Practice Address - Fax:281-564-0132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental