Provider Demographics
NPI:1619902921
Name:STOLBERG, MARILYN J (DDS)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:J
Last Name:STOLBERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:JEAN
Other - Last Name:RYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:160 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2102
Mailing Address - Country:US
Mailing Address - Phone:231-733-1224
Mailing Address - Fax:
Practice Address - Street 1:160 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2102
Practice Address - Country:US
Practice Address - Phone:231-733-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI744409338Medicaid