Provider Demographics
NPI:1437464294
Name:STARK, AMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
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 1:4600 CEDAR LAKE RD S APT 7
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3761
Mailing Address - Country:US
Mailing Address - Phone:612-206-5623
Mailing Address - Fax:612-659-8690
Practice Address - Street 1:606 24TH AVE S STE 200
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1437
Practice Address - Country:US
Practice Address - Phone:612-659-8689
Practice Address - Fax:612-658-8690
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR4711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice