1942429048 NPI number — DR. MICHELE DEBRA STARK DMD

Table of content: DR. MICHELE DEBRA STARK DMD (NPI 1942429048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942429048 NPI number — DR. MICHELE DEBRA STARK DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARK
Provider First Name:
MICHELE
Provider Middle Name:
DEBRA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
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:
1942429048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 E WALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORDEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62097-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-459-3626
Provider Business Mailing Address Fax Number:
618-459-7507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 E WALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORDEN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62097-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-459-3626
Provider Business Practice Location Address Fax Number:
618-459-7507
Provider Enumeration Date:
04/25/2007

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: 1223G0001X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1003853 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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