Provider Demographics
NPI:1942429048
Name:STARK, MICHELE DEBRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:DEBRA
Last Name:STARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E WALL ST
Mailing Address - Street 2:
Mailing Address - City:WORDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62097-1306
Mailing Address - Country:US
Mailing Address - Phone:618-459-3626
Mailing Address - Fax:618-459-7507
Practice Address - Street 1:224 E WALL ST
Practice Address - Street 2:
Practice Address - City:WORDEN
Practice Address - State:IL
Practice Address - Zip Code:62097-1306
Practice Address - Country:US
Practice Address - Phone:618-459-3626
Practice Address - Fax:618-459-7507
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003853Medicaid