Provider Demographics
NPI:1497443980
Name:HOLLIDAY, KYLIE LARUE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LARUE
Last Name:HOLLIDAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 CITYPLACE WEST BLVD APT 437
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-0360
Mailing Address - Country:US
Mailing Address - Phone:928-713-4198
Mailing Address - Fax:
Practice Address - Street 1:8222 BRUTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1902
Practice Address - Country:US
Practice Address - Phone:214-398-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX397651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program