Provider Demographics
NPI:1174600274
Name:STARK, THOMAS (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 STATE HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-3457
Mailing Address - Country:US
Mailing Address - Phone:732-249-3350
Mailing Address - Fax:732-249-3353
Practice Address - Street 1:1323 STATE HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3457
Practice Address - Country:US
Practice Address - Phone:732-249-3350
Practice Address - Fax:732-249-3353
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5561170001Medicare NSC
NJV04133Medicare UPIN
NJ088751Medicare ID - Type Unspecified
V04133Medicare UPIN