Provider Demographics
NPI:1376676171
Name:HOLLIS, BRENDA LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LYNN
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 SALEM CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2809
Mailing Address - Country:US
Mailing Address - Phone:850-309-1299
Mailing Address - Fax:850-309-1399
Practice Address - Street 1:147 SALEM CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2809
Practice Address - Country:US
Practice Address - Phone:850-309-1299
Practice Address - Fax:850-309-1399
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-154181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice