MEDICARE: HARRY HOLIDAY

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	1223G0001X	General Practice Dentistry	DN010595	GA

General Provider Information

NPI Number	:	1043293640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARRY HOLIDAY

Provider Business Mailing Address
First Line	:	347 MEDICAL GROUP, 3278 MITCHELL BLVD
Second Line	:
City	:	MOODY A F B
State	:	GA
Zip	:	31699-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	347 MEDICAL GROUP, 3278 MITCHELL BLVD
Second Line	:
City	:	MOODY A F B
State	:	GA
Zip	:	31699-0001
Country	:	US
Telephone Number	:	229-257-4304
Fax Number	:

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	07/08/2007

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