MEDICARE: DR. KEITH VAUGHN HOLLAND D.D.S.

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	122300000X	Dentist	DL6827	FL

General Provider Information

NPI Number	:	1619177169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH VAUGHN HOLLAND D.D.S.

Provider Business Mailing Address
First Line	:	4114 HERSCHEL ST
Second Line	:	SUITE 106A
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2206
Country	:	US
Telephone Number	:	904-389-3694
Fax Number	:

Provider Business Practice Location Address
First Line	:	4114 HERSCHEL ST
Second Line	:	SUITE 106A
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2206
Country	:	US
Telephone Number	:	904-389-3694
Fax Number	:

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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