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General NPI Number Information
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NPI Number | 1154105542
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Entity Type | Organization
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Legal Business Name | KIDS TOOTH TEAM LAKE ORION PLLC
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Dates
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Enumeration Date | 08/24/2023
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 4749 S BALDWIN RD
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City | LAKE ORION
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State | MI
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Zip | 48359-2114
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Country | US
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Telephone | 810-252-6616
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Fax |
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Provider Business Mailing Address
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Address Line | 5141 MEADOWHILL TRL
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City | GRAND BLANC
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State | MI
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Zip | 48439-8339
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Country | US
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Telephone | 810-252-6616
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Fax |
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Authorized Official
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Title or Position | OWNER / PEDIATRIC DENTIST
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Name | DR. KASEY MARIE STARK
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Credential | DDS
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Telephone | 810-252-6616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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