MEDICARE: MARIAN DE STOPPELAAR DMD PC

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	1223P0221X	Pediatric Dentistry	2967	OR

General Provider Information

NPI Number	:	1871580225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIAN DE STOPPELAAR DMD PC

Provider Business Mailing Address
First Line	:	2305 S E WASHINGTON ST
Second Line	:	STE 103
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-7647
Country	:	US
Telephone Number	:	503-786-6895
Fax Number	:

Provider Business Practice Location Address
First Line	:	2305 S E WASHINGTON ST
Second Line	:	STE 103
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-7647
Country	:	US
Telephone Number	:	503-786-6895
Fax Number	:

Authorized Official
Title or Position	:	PRES OF PC DENTIST
Name	:	MARIAN L DE STOPPELAAR
Credential	:	DMD
Telephone Number	:	503-786-6895

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	08/22/2020

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