Provider Demographics
NPI:1760920334
Name:HOLLY DENTAL SERVICES P.C.
Entity type:Organization
Organization Name:HOLLY DENTAL SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAM
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-359-3113
Mailing Address - Street 1:14015 HOLLY AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3433
Mailing Address - Country:US
Mailing Address - Phone:718-359-3113
Mailing Address - Fax:718-321-1478
Practice Address - Street 1:14015 HOLLY AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3433
Practice Address - Country:US
Practice Address - Phone:718-359-3113
Practice Address - Fax:718-321-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0581811261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental