MEDICARE: DR. MARTHA MANGUM HOLLAND D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	4186-21	MS
2	1223P0221X	Pediatric Dentistry	0442000258	VA

General Provider Information

NPI Number	:	1316322233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTHA MANGUM HOLLAND D.M.D.

Provider Business Mailing Address
First Line	:	521 N 11TH ST
Second Line	:	BOX 980566
City	:	RICHMOND
State	:	VA
Zip	:	23298-5045
Country	:	US
Telephone Number	:	804-828-9095
Fax Number	:

Provider Business Practice Location Address
First Line	:	5315 HIGHWAY 18 W
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-9421
Country	:	US
Telephone Number	:	601-922-0066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2015
Last Update Date	:	08/14/2024

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