MEDICARE: SALLY A. STOMMEN 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	12850	MI

General Provider Information

NPI Number	:	1871566612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY A. STOMMEN D.D.S.

Provider Business Mailing Address
First Line	:	11745 E MICHIGAN AVE
Second Line	:	P.O. BOX 275
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-5018
Fax Number	:	517-522-3708

Provider Business Practice Location Address
First Line	:	11745 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9219
Country	:	US
Telephone Number	:	517-522-5018
Fax Number	:	517-522-3708

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

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	07/08/2007

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