Provider Demographics
NPI:1750645420
Name:ROSARIO I. HOLLAND DDS INC.
Entity Type:Organization
Organization Name:ROSARIO I. HOLLAND DDS INC.
Other - Org Name:LIFETIME SMILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSARIO
Authorized Official - Middle Name:I
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-679-0697
Mailing Address - Street 1:15418 HAWTHORNE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3828
Mailing Address - Country:US
Mailing Address - Phone:310-679-0697
Mailing Address - Fax:
Practice Address - Street 1:15418 HAWTHORNE BLVD
Practice Address - Street 2:STE A
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-3828
Practice Address - Country:US
Practice Address - Phone:310-679-0697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA571471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB57147Medicaid