Provider Demographics
NPI:1194776682
Name:STARK, ROXANA EHTESSABIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ROXANA
Middle Name:EHTESSABIAN
Last Name:STARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 LARGO CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5129
Mailing Address - Country:US
Mailing Address - Phone:859-559-2943
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-9707
Practice Address - Fax:859-257-5859
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214671223G0001X
KY91611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice