Provider Demographics
NPI:1669766937
Name:HOLLIS, BERNARD MATT (DDS)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:MATT
Last Name:HOLLIS
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 1:117 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-2743
Mailing Address - Country:US
Mailing Address - Phone:318-375-2851
Mailing Address - Fax:
Practice Address - Street 1:4530 BENTON RD STE 200
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2435
Practice Address - Country:US
Practice Address - Phone:318-375-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice