Healthcare Provider Details

I. General information

NPI: 1124324876
Provider Name (Legal Business Name): HOLLY ANN MCKNIGHT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY ANN BOUREK D.D.S.

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4202 N 32ND ST STE D
PHOENIX AZ
85018-4764
US

IV. Provider business mailing address

4202 N 32ND ST STE D
PHOENIX AZ
85018-4764
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-0650
  • Fax:
Mailing address:
  • Phone: 602-956-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD008705
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: