Provider Demographics
NPI:1700871118
Name:STOLLER, CHAD (DDS, PA-C)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:STOLLER
Suffix:
Gender:M
Credentials:DDS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4761
Mailing Address - Country:US
Mailing Address - Phone:260-482-6689
Mailing Address - Fax:
Practice Address - Street 1:2828 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4761
Practice Address - Country:US
Practice Address - Phone:260-482-6689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003571363AM0700X, 363A00000X
IN12013438A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970021317OtherRAILROAD MEDICARE
MID16091101Medicare Oscar/Certification