Provider Demographics
NPI:1871566612
Name:STOMMEN, SALLY A (DDS)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:STOMMEN
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 1:11745 E MICHIGAN AVE
Mailing Address - Street 2:P.O. BOX 275
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9219
Mailing Address - Country:US
Mailing Address - Phone:517-522-5018
Mailing Address - Fax:517-522-3708
Practice Address - Street 1:11745 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9219
Practice Address - Country:US
Practice Address - Phone:517-522-5018
Practice Address - Fax:517-522-3708
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI128501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice