Provider Demographics
NPI:1043609738
Name:HOLLAND FAMILY DENTISTRY
Entity type:Organization
Organization Name:HOLLAND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALISHA
Authorized Official - Middle Name:LEONE
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-396-1058
Mailing Address - Street 1:545 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4749
Mailing Address - Country:US
Mailing Address - Phone:616-396-1058
Mailing Address - Fax:
Practice Address - Street 1:545 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4749
Practice Address - Country:US
Practice Address - Phone:616-396-1058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1891743456OtherNPI INDIVIDUAL
MI124064660Medicaid