1154105542 NPI number — KIDS TOOTH TEAM LAKE ORION PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154105542 NPI number — KIDS TOOTH TEAM LAKE ORION PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS TOOTH TEAM LAKE ORION PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154105542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5141 MEADOWHILL TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-8339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-252-6616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4749 S BALDWIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ORION
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48359-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-252-6616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2023

Additional Information

Authorized Official

Authorized Official Last Name:
STARK
Authorized Official First Name:
KASEY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER / PEDIATRIC DENTIST
Authorized Official Telephone Number:
810-252-6616

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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