Healthcare Provider Details

I. General information

NPI: 1871580225
Provider Name (Legal Business Name): MARIAN DE STOPPELAAR DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 S E WASHINGTON ST STE 103
MILWAUKIE OR
97222-7647
US

IV. Provider business mailing address

2305 S E WASHINGTON ST STE 103
MILWAUKIE OR
97222-7647
US

V. Phone/Fax

Practice location:
  • Phone: 503-786-6895
  • Fax:
Mailing address:
  • Phone: 503-786-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2967
License Number StateOR

VIII. Authorized Official

Name: MARIAN L DE STOPPELAAR
Title or Position: PRES OF PC DENTIST
Credential: DMD
Phone: 503-786-6895