Basic Information
| Provider Information | |||||||||
| NPI: | 1659704799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 SHAWMUT AVE | ||||||||
| Address2: | APT 404 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705304486 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 KNEELAND ST | ||||||||
| Address2: | 8TH FLOOR - PEDIATRIC DENTISTRY | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021111527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176366971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DL11938 | MA | Y | Dental Providers | Dentist |
No ID Information.