Provider Demographics
NPI:1740411537
Name:STARK, CATHERINE SUSAN (RDH, ORALFACIAL MYOL)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:SUSAN
Last Name:STARK
Suffix:
Gender:F
Credentials:RDH, ORALFACIAL MYOL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 S NOVA RD
Mailing Address - Street 2:#201
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9281
Mailing Address - Country:US
Mailing Address - Phone:386-212-5071
Mailing Address - Fax:603-687-4663
Practice Address - Street 1:3930 S NOVA RD
Practice Address - Street 2:#201
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9281
Practice Address - Country:US
Practice Address - Phone:386-212-5071
Practice Address - Fax:603-687-4663
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH007569124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist