Provider Demographics
NPI:1023510906
Name:HOLLIS, STEPHANIE R (RDH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2441
Practice Address - Street 1:115 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638-9300
Practice Address - Country:US
Practice Address - Phone:573-663-3177
Practice Address - Fax:573-663-3188
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017988124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist