Provider Demographics
NPI:1811082753
Name:STARK, JOHN D (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:STARK
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 1:1258 W SOUTH JORDAN PKWY
Mailing Address - Street 2:STE 204
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4712
Mailing Address - Country:US
Mailing Address - Phone:801-254-0713
Mailing Address - Fax:
Practice Address - Street 1:2120 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7131
Practice Address - Country:US
Practice Address - Phone:801-254-0713
Practice Address - Fax:801-254-0417
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56561361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice