Provider Demographics
NPI:1831275478
Name:MCCLENDON, HOLLY WILSON (DMD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:WILSON
Last Name:MCCLENDON
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 1:107 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2325
Mailing Address - Country:US
Mailing Address - Phone:270-247-8250
Mailing Address - Fax:
Practice Address - Street 1:107 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2325
Practice Address - Country:US
Practice Address - Phone:270-247-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice