Provider Demographics
NPI:1518698950
Name:STARK, JAKOB (DDS)
Entity Type:Individual
Prefix:
First Name:JAKOB
Middle Name:
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 1:90 HOPE DR, BLDG 6000
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1062
Mailing Address - Country:US
Mailing Address - Phone:208-828-7300
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR, BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist