Healthcare Provider Details

I. General information

NPI: 1841371630
Provider Name (Legal Business Name): MITCHELL A STARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14955 SHADY GROVE RD SUITE 330
ROCKVILLE MD
20850
US

IV. Provider business mailing address

14955 SHADY GROVE RD SUITE 330
ROCKVILLE MD
20850
US

V. Phone/Fax

Practice location:
  • Phone: 301-340-0101
  • Fax: 301-340-1689
Mailing address:
  • Phone: 301-340-0101
  • Fax: 301-340-1689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11426
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN5790
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: