Provider Demographics
NPI:1376994525
Name:CAVNESS, HOLLY (RDH)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:CAVNESS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-9400
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:
Practice Address - Street 1:1407 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3315
Practice Address - Country:US
Practice Address - Phone:573-778-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015018845124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist