Provider Demographics
NPI:1871663427
Name:HOLLY, RANDOLPH (DDS)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:HOLLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5221
Mailing Address - Country:US
Mailing Address - Phone:607-757-0455
Mailing Address - Fax:607-757-9375
Practice Address - Street 1:1003 MONROE STREET
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760
Practice Address - Country:US
Practice Address - Phone:607-757-0455
Practice Address - Fax:607-757-9375
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03699011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU06276Medicare UPIN