Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 19501 | TX |
NPI | 1003812033 |
---|---|
Provider Name | Dr. Lara Kirstin Holly |
First Address | Dallas, TX 75231-4237 |
Second Address | Dallas, TX 75231-4237 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2005 |
Last Update Date | 08/07/2007 |