1780896274 NPI number — KENNETH E. HOLLAND, JR., DDS, MS, PC

Table of content: (NPI 1780896274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780896274 NPI number — KENNETH E. HOLLAND, JR., DDS, MS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH E. HOLLAND, JR., DDS, MS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780896274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8841 EAST FLORENTINE ROAD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
PRESCOTT VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-759-9200
Provider Business Mailing Address Fax Number:
928-775-0248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8841 EAST FLORENTINE ROAD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-759-9200
Provider Business Practice Location Address Fax Number:
928-775-0248
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESICENT
Authorized Official Telephone Number:
928-759-9200

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  4291 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 422056 . This is a "DEPT OF ECOMON SEC - CMDP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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