Provider Demographics
NPI:1467606608
Name:HOLLEY FAMILY DENTISTRY FREDERICKSBURG
Entity Type:Organization
Organization Name:HOLLEY FAMILY DENTISTRY FREDERICKSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIVESAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-785-5885
Mailing Address - Street 1:974 BRAGG RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6979
Mailing Address - Country:US
Mailing Address - Phone:540-785-5885
Mailing Address - Fax:
Practice Address - Street 1:974 BRAGG RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-6979
Practice Address - Country:US
Practice Address - Phone:540-785-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA74311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6239Medicaid