MEDICARE: DR. AMY STARK D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	R471	MN

General Provider Information

NPI Number	:	1437464294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY STARK D.D.S

Provider Business Mailing Address
First Line	:	4600 CEDAR LAKE RD S APT 7
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-3761
Country	:	US
Telephone Number	:	612-206-5623
Fax Number	:	612-659-8690

Provider Business Practice Location Address
First Line	:	606 24TH AVE S STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454-1437
Country	:	US
Telephone Number	:	612-659-8689
Fax Number	:	612-658-8690

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	08/17/2010

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