Provider Demographics
NPI:1063058097
Name:STOLT, JEAN M (RDH)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:STOLT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 M 119 STE G
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9373
Mailing Address - Country:US
Mailing Address - Phone:231-348-3970
Mailing Address - Fax:231-348-3946
Practice Address - Street 1:3434 M 119 STE G
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9373
Practice Address - Country:US
Practice Address - Phone:231-348-3970
Practice Address - Fax:231-348-3946
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012500124Q00000X
MI29010182391223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2902012500Medicaid