Provider Demographics
NPI:1558681866
Name:EYDENBERG, HOLLY (DMD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:EYDENBERG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3943 116TH ST NE
Mailing Address - Street 2:STE. 103
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8448
Mailing Address - Country:US
Mailing Address - Phone:360-651-9580
Mailing Address - Fax:
Practice Address - Street 1:3943 116TH ST NE
Practice Address - Street 2:STE. 103
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8448
Practice Address - Country:US
Practice Address - Phone:360-651-9580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE602093031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program