Healthcare Provider Details

I. General information

NPI: 1417519331
Provider Name (Legal Business Name): DYLAN STARCK DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 W MARKET ST
MEQUON WI
53092-5053
US

IV. Provider business mailing address

2637 2ND AVE
MONROE WI
53566-3501
US

V. Phone/Fax

Practice location:
  • Phone: 82-147-3996
  • Fax:
Mailing address:
  • Phone: 608-214-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2952000584
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901600432
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: