Provider Demographics
NPI:1285971523
Name:BURGOS, HOLLI DILLON (RDHAP)
Entity type:Individual
Prefix:
First Name:HOLLI
Middle Name:DILLON
Last Name:BURGOS
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 ANTON WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1508
Mailing Address - Country:US
Mailing Address - Phone:909-985-8555
Mailing Address - Fax:
Practice Address - Street 1:1867 ANTON WAY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1508
Practice Address - Country:US
Practice Address - Phone:909-985-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 437124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist