Provider Demographics
NPI:1154105542
Name:KIDS TOOTH TEAM LAKE ORION PLLC
Entity type:Organization
Organization Name:KIDS TOOTH TEAM LAKE ORION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-252-6616
Mailing Address - Street 1:5141 MEADOWHILL TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8339
Mailing Address - Country:US
Mailing Address - Phone:810-252-6616
Mailing Address - Fax:
Practice Address - Street 1:4749 S BALDWIN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2114
Practice Address - Country:US
Practice Address - Phone:810-252-6616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty