Provider Demographics
NPI:1003834268
Name:CANTRELL, HOLLY R (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:R
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-4363
Mailing Address - Country:US
Mailing Address - Phone:706-778-5093
Mailing Address - Fax:706-776-2708
Practice Address - Street 1:108 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-4363
Practice Address - Country:US
Practice Address - Phone:706-778-5093
Practice Address - Fax:706-776-2708
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA112621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26-3779388OtherEIN