Healthcare Provider Details

I. General information

NPI: 1154760411
Provider Name (Legal Business Name): TYLER J HOLLEY MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 01/08/2024
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W GORE ST STE 302
ORLANDO FL
32806-1014
US

IV. Provider business mailing address

207 W GORE ST STE 302
ORLANDO FL
32806-1014
US

V. Phone/Fax

Practice location:
  • Phone: 407-839-8407
  • Fax: 407-839-8446
Mailing address:
  • Phone: 407-839-8407
  • Fax: 407-839-8446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7135
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN25920
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7135
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME144719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: