Provider Demographics
NPI:1679785612
Name:HOLLEY, MANDY LEE (DDS)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LEE
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628
Mailing Address - Country:US
Mailing Address - Phone:512-819-9494
Mailing Address - Fax:512-819-9128
Practice Address - Street 1:3613 WILLIAMS DR.
Practice Address - Street 2:SUITE 1001
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628
Practice Address - Country:US
Practice Address - Phone:512-819-9100
Practice Address - Fax:512-819-9128
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice