Provider Demographics
NPI:1417385931
Name:HOLLEY FAMILY DENTISTRY OF VIRGINIA BEACH
Entity Type:Organization
Organization Name:HOLLEY FAMILY DENTISTRY OF VIRGINIA BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MCNAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-393-2401
Mailing Address - Street 1:940 GENERAL BOOTH BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:757-428-1188
Practice Address - Street 1:940 GENERAL BOOTH BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451
Practice Address - Country:US
Practice Address - Phone:757-425-1155
Practice Address - Fax:757-428-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007431122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty