Provider Demographics
NPI:1932263944
Name:STARK, BRIAN ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANTHONY
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:N84W15959 APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3044
Mailing Address - Country:US
Mailing Address - Phone:262-251-6555
Mailing Address - Fax:262-251-9518
Practice Address - Street 1:N84W15959 APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3044
Practice Address - Country:US
Practice Address - Phone:262-251-6555
Practice Address - Fax:262-251-9518
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001496G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice