Provider Demographics
NPI:1477083855
Name:STARK, KASEY MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KASEY
Middle Name:MARIE
Last Name:STARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 E KIRBY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-4122
Mailing Address - Country:US
Mailing Address - Phone:810-252-6616
Mailing Address - Fax:
Practice Address - Street 1:380 N STATE RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9486
Practice Address - Country:US
Practice Address - Phone:810-631-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010223171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice