=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316322233
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA MANGUM HOLLAND D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 08/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5315 HIGHWAY 18 W
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39209-9421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-922-0066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 521 N 11TH ST BOX 980566
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23298-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-828-9095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 4186-21
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 0442000258
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------