Healthcare Provider Details

I. General information

NPI: 1598185878
Provider Name (Legal Business Name): MARJEAN MARIE STAMM RDH, BSDH, PHRDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 N 164TH ST
OMAHA NE
68118-2504
US

IV. Provider business mailing address

656 N 164TH ST
OMAHA NE
68118-2504
US

V. Phone/Fax

Practice location:
  • Phone: 402-657-1802
  • Fax:
Mailing address:
  • Phone: 402-657-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1367
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: