Provider Demographics
NPI:1881965879
Name:SHANNA COUCH HOLLIDAY
Entity type:Organization
Organization Name:SHANNA COUCH HOLLIDAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-439-1069
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-0799
Mailing Address - Country:US
Mailing Address - Phone:606-439-1079
Mailing Address - Fax:
Practice Address - Street 1:251 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9470
Practice Address - Country:US
Practice Address - Phone:606-439-1079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000262Medicaid