Provider Demographics
NPI:1265644249
Name:HOLLAND, KENNETH EUGENE JR (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EUGENE
Last Name:HOLLAND
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 W SAHUARO DR
Mailing Address - Street 2:APT 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5070
Mailing Address - Country:US
Mailing Address - Phone:928-710-4974
Mailing Address - Fax:
Practice Address - Street 1:13821 N 35TH DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-5541
Practice Address - Country:US
Practice Address - Phone:928-710-4974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422056OtherDEPT OF ECOMON SEC - CMDP