Provider Demographics
NPI:1457598849
Name:HOLLER, MICHAEL KENNETH (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:HOLLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 23RD AVE BLDG 914
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4312
Mailing Address - Country:US
Mailing Address - Phone:805-982-5584
Mailing Address - Fax:
Practice Address - Street 1:720 23RD AVE BLDG 914
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4312
Practice Address - Country:US
Practice Address - Phone:805-982-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA641871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics