Provider Demographics
NPI:1609930627
Name:BRIAN A. STARK, D.D.S., S.C.
Entity Type:Organization
Organization Name:BRIAN A. STARK, D.D.S., S.C.
Other - Org Name:AVENUE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-251-6555
Mailing Address - Street 1:N84W15959 APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3044
Mailing Address - Country:US
Mailing Address - Phone:262-251-6555
Mailing Address - Fax:262-251-9518
Practice Address - Street 1:N84W15959 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3044
Practice Address - Country:US
Practice Address - Phone:262-251-6555
Practice Address - Fax:262-251-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental