Provider Demographics
NPI:1710601844
Name:HOLYFIELD, BARRY GRAY
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:GRAY
Last Name:HOLYFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 ASSOCIATE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3879
Mailing Address - Country:US
Mailing Address - Phone:336-621-2465
Mailing Address - Fax:
Practice Address - Street 1:3501 ASSOCIATE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3879
Practice Address - Country:US
Practice Address - Phone:336-621-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043948631OtherNPPES