Provider Demographics
NPI:1326131970
Name:STARK, GEOFFREY A (DMD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:A
Last Name:STARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 NW HUGHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8844
Mailing Address - Country:US
Mailing Address - Phone:541-672-2872
Mailing Address - Fax:541-672-6885
Practice Address - Street 1:1602 NW HUGHWOOD CT
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-8844
Practice Address - Country:US
Practice Address - Phone:541-672-2872
Practice Address - Fax:541-672-6885
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist