MEDICARE: DR. TERRILL LEE STOLLER D.D.S.

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	12007302A	IN

General Provider Information

NPI Number	:	1649337494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRILL LEE STOLLER D.D.S.

Provider Business Mailing Address
First Line	:	60420 US 31 S
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-5138
Country	:	US
Telephone Number	:	574-291-6020
Fax Number	:	574-291-6051

Provider Business Practice Location Address
First Line	:	60420 US 31 S
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-5138
Country	:	US
Telephone Number	:	574-291-6020
Fax Number	:	574-291-6051

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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