Provider Demographics
NPI:1194989624
Name:STORK, JAMES T (DDS, MS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:STORK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 WESTOWN PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6760
Mailing Address - Country:US
Mailing Address - Phone:515-225-4310
Mailing Address - Fax:866-259-5317
Practice Address - Street 1:4090 WESTOWN PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6760
Practice Address - Country:US
Practice Address - Phone:515-225-4310
Practice Address - Fax:866-259-5317
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND125801223X0400X
IA088921223X0400X
MO20110161461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid