Provider Demographics
NPI:1104256106
Name:STORLIE, MICHELLE (ADT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:STORLIE
Suffix:
Gender:
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-2406
Mailing Address - Country:US
Mailing Address - Phone:651-457-6231
Mailing Address - Fax:651-457-6231
Practice Address - Street 1:1246 GORMAN AVE
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-2406
Practice Address - Country:US
Practice Address - Phone:651-457-6231
Practice Address - Fax:651-457-6231
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT25125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist