Provider Demographics
NPI:1407176290
Name:HOLLOWAY-JANKOWSKI, JETTA RENAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JETTA
Middle Name:RENAE
Last Name:HOLLOWAY-JANKOWSKI
Suffix:
Gender:F
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:PO BOX 466
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:KS
Mailing Address - Zip Code:67420-0466
Mailing Address - Country:US
Mailing Address - Phone:785-738-3758
Mailing Address - Fax:785-738-2737
Practice Address - Street 1:208 S MILL ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420-3239
Practice Address - Country:US
Practice Address - Phone:785-738-3758
Practice Address - Fax:785-738-2737
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS606451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice