Provider Demographics
NPI:1720275688
Name:HOLLER, JOHN LEONARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEONARD
Last Name:HOLLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 W. SWAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-475-1750
Mailing Address - Fax:209-475-1751
Practice Address - Street 1:1147 W. SWAIN ROAD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-475-1750
Practice Address - Fax:209-475-1751
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2016-03-07
Deactivation Date:2013-01-24
Deactivation Code:
Reactivation Date:2016-03-07
Provider Licenses
StateLicense IDTaxonomies
CA25905122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist