Provider Demographics
NPI:1699901595
Name:STARK, FREDERICK WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WAYNE
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 1:700 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-3325
Mailing Address - Country:US
Mailing Address - Phone:620-241-5000
Mailing Address - Fax:
Practice Address - Street 1:1710 E MADISON AVE STE 600
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2285
Practice Address - Country:US
Practice Address - Phone:316-788-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS606801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice