Provider Demographics
NPI:1265604193
Name:HOLLY SPRINGS FAMILY DENTISTRY
Entity type:Organization
Organization Name:HOLLY SPRINGS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-290-2772
Mailing Address - Street 1:190 ROSEWOOD CENTER DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540
Mailing Address - Country:US
Mailing Address - Phone:919-290-2772
Mailing Address - Fax:919-270-2773
Practice Address - Street 1:190 ROSEWOOD CENTER DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540
Practice Address - Country:US
Practice Address - Phone:919-290-2772
Practice Address - Fax:919-270-2773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902VVMedicaid