Provider Demographics
NPI:1295860617
Name:STARK, MICHELLE LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LYNN
Last Name:STARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-2553
Mailing Address - Country:US
Mailing Address - Phone:530-842-3900
Mailing Address - Fax:
Practice Address - Street 1:544 N MAIN ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-2553
Practice Address - Country:US
Practice Address - Phone:530-842-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39338OtherDENTAL LICENSE NUMBER