Provider Demographics
NPI:1437364809
Name:KENNETH EUGENE HOLLAND, JR., DDS, MS, PLLC
Entity Type:Organization
Organization Name:KENNETH EUGENE HOLLAND, JR., DDS, MS, PLLC
Other - Org Name:KENNETH E HOLLAND, JR, DDS, MS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:928-710-4974
Mailing Address - Street 1:1560 W SAHUARO DR
Mailing Address - Street 2:APT 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5070
Mailing Address - Country:US
Mailing Address - Phone:928-710-4974
Mailing Address - Fax:
Practice Address - Street 1:13821 N 35TH DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-5541
Practice Address - Country:US
Practice Address - Phone:928-710-4974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422056OtherDEPT OF ECONOM SEC - CMDP