Provider Demographics
NPI:1194395186
Name:HOLSTON, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:HOLSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 CAMPUS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-9706
Mailing Address - Country:US
Mailing Address - Phone:276-525-4487
Mailing Address - Fax:
Practice Address - Street 1:616 CAMPUS DR STE 100
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-9706
Practice Address - Country:US
Practice Address - Phone:276-525-4487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417524122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist