Provider Demographics
NPI:1588860175
Name:STOLL, ELLERY ANN (DDS)
Entity Type:Individual
Prefix:
First Name:ELLERY
Middle Name:ANN
Last Name:STOLL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 LAKE TAHOE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7920
Mailing Address - Country:US
Mailing Address - Phone:530-544-2208
Mailing Address - Fax:
Practice Address - Street 1:3351 LAKE TAHOE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7920
Practice Address - Country:US
Practice Address - Phone:530-544-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist