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General NPI Number Information
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NPI Number | 1528464492
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Entity Type | Organization
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Legal Business Name | HOLLOWAY FAMILY DENTISTRY
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Dates
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Enumeration Date | 11/05/2014
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Last Update Date | 11/05/2014
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Provider Practice Location Address
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Address Line | 608 HIGHWAY 76 W
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City | CLAYTON
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State | GA
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Zip | 30525-5266
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Country | US
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Telephone | 706-782-3042
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 725
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City | CLAYTON
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State | GA
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Zip | 30525-0019
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Country | US
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Telephone | 706-782-3042
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEREMY HOLLOWAY
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Credential | D.M.D
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Telephone | 706-782-3042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN014627
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License Number State | GA
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