Healthcare Provider Details

I. General information

NPI: 1912035163
Provider Name (Legal Business Name): DR. CORY M. STARK D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E 12450 S #100
DRAPER UT
84020-8056
US

IV. Provider business mailing address

112 E 12450 S #100
DRAPER UT
84020-8056
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-6751
  • Fax: 801-571-4156
Mailing address:
  • Phone: 801-571-6751
  • Fax: 801-571-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number144937-9923
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier529865775005
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: MRS. CARRIE LOUISE CAMPBELL
Title or Position: BUSINESS MANAGER
Credential:
Phone: 801-571-6751