Provider Demographics
NPI:1184780173
Name:COOK, HOLLY L (DDS)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:L
Last Name:COOK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:COOK-STADING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2229 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3411
Mailing Address - Country:US
Mailing Address - Phone:530-541-7862
Mailing Address - Fax:530-541-7863
Practice Address - Street 1:2229 BARTON AVE
Practice Address - Street 2:
Practice Address - City:SO. LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3411
Practice Address - Country:US
Practice Address - Phone:530-541-7862
Practice Address - Fax:530-541-7863
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA367411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice