Provider Demographics
NPI:1841371630
Name:STARK, MITCHELL A (DDS)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:A
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 1:14955 SHADY GROVE RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-340-0101
Mailing Address - Fax:301-340-1689
Practice Address - Street 1:14955 SHADY GROVE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-340-0101
Practice Address - Fax:301-340-1689
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD114261223S0112X
DCDEN57901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
014942 M26Medicare ID - Type Unspecified
U54307Medicare UPIN