=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770971947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY LINH RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2014
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9225 DOERR RD BLDG 1220
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-300-5547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 BIRDS NEST WAY
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22405-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-300-5547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 27118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------