Provider Demographics
NPI:1386640480
Name:HOLLIS, JEFFREY L (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11282 M 140
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9405
Mailing Address - Country:US
Mailing Address - Phone:269-637-8611
Mailing Address - Fax:269-637-8956
Practice Address - Street 1:11282 M 140
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9405
Practice Address - Country:US
Practice Address - Phone:269-637-8611
Practice Address - Fax:269-637-8956
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
MI29010126141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice