Provider Demographics
NPI:1528392115
Name:FLETCHER-STARK, MADELYN LUCILLE (DDS)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:LUCILLE
Last Name:FLETCHER-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 1:8521 GOLF COURSE RD NW STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4549
Mailing Address - Country:US
Mailing Address - Phone:505-897-6453
Mailing Address - Fax:
Practice Address - Street 1:8521 GOLF COURSE RD NW STE 116
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4549
Practice Address - Country:US
Practice Address - Phone:505-897-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472591223P0700X
NMDD45081223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47259OtherLICENSE NUMBER