Provider Demographics
NPI:1306032610
Name:HOLLEY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:HOLLEY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-595-3503
Mailing Address - Street 1:446 EFFINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3416
Mailing Address - Country:US
Mailing Address - Phone:757-393-2401
Mailing Address - Fax:757-595-3816
Practice Address - Street 1:446 EFFINGHAM ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3416
Practice Address - Country:US
Practice Address - Phone:757-393-2401
Practice Address - Fax:757-595-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04701074311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7831587Medicaid