Provider Demographics
NPI:1306287032
Name:JORGENSEN, HOLLY RAE (COLLABORATIVE RDH)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:RAE
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:COLLABORATIVE RDH
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:RAE
Other - Last Name:BLANCHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 OAKDALE ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4216
Mailing Address - Country:US
Mailing Address - Phone:507-455-4063
Mailing Address - Fax:
Practice Address - Street 1:155 OAKDALE ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4216
Practice Address - Country:US
Practice Address - Phone:507-455-4063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH8035124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist