Provider Demographics
NPI:1780896274
Name:KENNETH E. HOLLAND, JR., DDS, MS, PC
Entity type:Organization
Organization Name:KENNETH E. HOLLAND, JR., DDS, MS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESICENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:928-759-9200
Mailing Address - Street 1:8841 EAST FLORENTINE ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-759-9200
Mailing Address - Fax:928-775-0248
Practice Address - Street 1:8841 EAST FLORENTINE ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-759-9200
Practice Address - Fax:928-775-0248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422056OtherDEPT OF ECOMON SEC - CMDP