Provider Demographics
NPI:1649596248
Name:HOLLY, DENNIS JON (DMD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JON
Last Name:HOLLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3508
Mailing Address - Country:US
Mailing Address - Phone:971-235-0777
Mailing Address - Fax:
Practice Address - Street 1:1785 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3508
Practice Address - Country:US
Practice Address - Phone:971-235-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist