Provider Demographics
NPI:1053350512
Name:HOLLY, EDWARD KELLY (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:KELLY
Last Name:HOLLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 KEMPER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4906
Mailing Address - Country:US
Mailing Address - Phone:619-224-2828
Mailing Address - Fax:619-224-2636
Practice Address - Street 1:3340 KEMPER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4906
Practice Address - Country:US
Practice Address - Phone:619-224-2828
Practice Address - Fax:619-224-2636
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice