1740411537 NPI number — CATHERINE SUSAN STARK RDH, ORALFACIAL MYOL

Table of content: CATHERINE SUSAN STARK RDH, ORALFACIAL MYOL (NPI 1740411537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740411537 NPI number — CATHERINE SUSAN STARK RDH, ORALFACIAL MYOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARK
Provider First Name:
CATHERINE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDH, ORALFACIAL MYOL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740411537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3930 S NOVA RD
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32127-9281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-212-5071
Provider Business Mailing Address Fax Number:
603-687-4663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3930 S NOVA RD
Provider Second Line Business Practice Location Address:
#201
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-9281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-212-5071
Provider Business Practice Location Address Fax Number:
603-687-4663
Provider Enumeration Date:
07/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  DH007569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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