MEDICARE: DR. LARA KIRSTIN HOLLY D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	19501	TX

General Provider Information

NPI Number	:	1003812033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARA KIRSTIN HOLLY D.M.D.

Provider Business Mailing Address
First Line	:	8355 WALNUT HILL LN
Second Line	:	STE 125
City	:	DALLAS
State	:	TX
Zip	:	75231-4237
Country	:	US
Telephone Number	:	214-378-8868
Fax Number	:	214-378-6182

Provider Business Practice Location Address
First Line	:	8355 WALNUT HILL LN
Second Line	:	STE 125
City	:	DALLAS
State	:	TX
Zip	:	75231-4237
Country	:	US
Telephone Number	:	214-378-8868
Fax Number	:	214-378-6182

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/08/2007

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