Provider Demographics
NPI:1154760411
Name:HOLLEY, TYLER J (MD, DDS)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:J
Last Name:HOLLEY
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W GORE ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1014
Mailing Address - Country:US
Mailing Address - Phone:407-839-8407
Mailing Address - Fax:407-839-8446
Practice Address - Street 1:207 W GORE ST STE 302
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1014
Practice Address - Country:US
Practice Address - Phone:407-839-8407
Practice Address - Fax:407-839-8446
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71351223S0112X, 204E00000X
FLDN259201223S0112X
FLME144719204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105884500Medicaid
NE470785575-06Medicaid