Provider Demographics
NPI:1346574316
Name:STARK, DERRIK PALMER (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRIK
Middle Name:PALMER
Last Name:STARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:360-577-0566
Mailing Address - Fax:
Practice Address - Street 1:820 OCEAN BEACH HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4080
Practice Address - Country:US
Practice Address - Phone:360-577-0566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 600945861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice