Provider Demographics
NPI:1386047512
Name:MOUNT HOLLY DENTISTRY
Entity type:Organization
Organization Name:MOUNT HOLLY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-827-8446
Mailing Address - Street 1:126 W CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1776
Mailing Address - Country:US
Mailing Address - Phone:704-827-8446
Mailing Address - Fax:704-827-6131
Practice Address - Street 1:126 W CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1776
Practice Address - Country:US
Practice Address - Phone:704-827-8446
Practice Address - Fax:704-827-6131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid