Provider Demographics
NPI:1033329123
Name:JEFFERY B. STOLLER D.D.S I.N.C
Entity Type:Organization
Organization Name:JEFFERY B. STOLLER D.D.S I.N.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-687-4345
Mailing Address - Street 1:4 E MAIN ST
Mailing Address - Street 2:P.O. BOX 46
Mailing Address - City:PLYMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:44865-1081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:OH
Practice Address - Zip Code:44865-1081
Practice Address - Country:US
Practice Address - Phone:419-687-4345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0559444Medicaid