Provider Demographics
NPI:1376311357
Name:HOLLIDAY, PATRICE RENAE
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:RENAE
Last Name:HOLLIDAY
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 1:15874 ROBSON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2643
Mailing Address - Country:US
Mailing Address - Phone:313-622-2119
Mailing Address - Fax:
Practice Address - Street 1:15874 ROBSON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2643
Practice Address - Country:US
Practice Address - Phone:313-622-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2903003575126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant