Provider Demographics
NPI:1912035163
Name:DR. CORY M. STARK D.D.S.
Entity Type:Organization
Organization Name:DR. CORY M. STARK D.D.S.
Other - Org Name:OUT OF THIS WORLD DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-6751
Mailing Address - Street 1:112 E 12450 S
Mailing Address - Street 2:#100
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8056
Mailing Address - Country:US
Mailing Address - Phone:801-571-6751
Mailing Address - Fax:801-571-4156
Practice Address - Street 1:112 E 12450 S
Practice Address - Street 2:#100
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8056
Practice Address - Country:US
Practice Address - Phone:801-571-6751
Practice Address - Fax:801-571-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144937-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529865775005Medicaid