Provider Demographics
NPI:1194326777
Name:KNIGHT, HOLLY SUZAHN
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:SUZAHN
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-9766
Mailing Address - Country:US
Mailing Address - Phone:918-500-1169
Mailing Address - Fax:
Practice Address - Street 1:427 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1528
Practice Address - Country:US
Practice Address - Phone:210-951-3280
Practice Address - Fax:210-858-9220
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK157306126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK157306OtherRDA- CONTRACTOR
AK157306OtherRDA