MEDICARE: DR. MARY J STAHLE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1301125	MI

General Provider Information

NPI Number	:	1639118979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY J STAHLE DDS

Provider Business Mailing Address
First Line	:	2532 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3663
Country	:	US
Telephone Number	:	517-784-5525
Fax Number	:	517-784-5101

Provider Business Practice Location Address
First Line	:	2532 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3663
Country	:	US
Telephone Number	:	517-784-5525
Fax Number	:	517-784-5101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/08/2007

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