Provider Demographics
NPI:1548384027
Name:SPARKS, GARRETT S (DDS)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:S
Last Name:SPARKS
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 1:2539 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-1619
Mailing Address - Country:US
Mailing Address - Phone:573-204-1126
Mailing Address - Fax:
Practice Address - Street 1:1166 GREENWAY DR STE A1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2919
Practice Address - Country:US
Practice Address - Phone:573-204-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010182131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice