Healthcare Provider Details

I. General information

NPI: 1073473237
Provider Name (Legal Business Name): KIDS TOOTH TEAM FENTON PPLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 N LEROY ST
FENTON MI
48430-2758
US

IV. Provider business mailing address

1110 N LEROY ST
FENTON MI
48430-2758
US

V. Phone/Fax

Practice location:
  • Phone: 248-422-0555
  • Fax:
Mailing address:
  • Phone: 248-422-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KASEY MARIE STARK
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 248-422-0555