Healthcare Provider Details

I. General information

NPI: 1194989624
Provider Name (Legal Business Name): JAMES T STORK DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4090 WESTOWN PKWY STE 101
WEST DES MOINES IA
50266-6760
US

IV. Provider business mailing address

4090 WESTOWN PKWY STE 101
WEST DES MOINES IA
50266-6760
US

V. Phone/Fax

Practice location:
  • Phone: 515-225-4310
  • Fax: 866-259-5317
Mailing address:
  • Phone: 515-225-4310
  • Fax: 866-259-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD12580
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number08892
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2011016146
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: