Provider Demographics
NPI:1144319161
Name:STARK, PAUL JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOHN
Last Name:STARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 S 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1501
Mailing Address - Country:US
Mailing Address - Phone:218-229-2741
Mailing Address - Fax:218-229-2741
Practice Address - Street 1:508 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:BIWABIK
Practice Address - State:MN
Practice Address - Zip Code:55708
Practice Address - Country:US
Practice Address - Phone:218-865-4131
Practice Address - Fax:218-865-4131
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND85591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice