Healthcare Provider Details

I. General information

NPI: 1033329123
Provider Name (Legal Business Name): JEFFERY B. STOLLER D.D.S I.N.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 E MAIN ST
PLYMOUTH OH
44865-1081
US

IV. Provider business mailing address

4 E MAIN ST P.O. BOX 46
PLYMOUTH OH
44865-1081
US

V. Phone/Fax

Practice location:
  • Phone: 419-687-4345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17426
License Number StateOH

VIII. Authorized Official

Name: JEFFERY STOLLER
Title or Position: DENTIST
Credential:
Phone: 419-687-4345