Provider Demographics
NPI:1972517126
Name:HOLLEMAN, SIDNEY ANTHONY JR (DDS)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:ANTHONY
Last Name:HOLLEMAN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4430
Mailing Address - Country:US
Mailing Address - Phone:817-336-6048
Mailing Address - Fax:817-334-0621
Practice Address - Street 1:1116 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4430
Practice Address - Country:US
Practice Address - Phone:817-336-6048
Practice Address - Fax:817-334-0621
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM473OtherBCBS ID #
TXM473OtherBCBS ID #
TX00M473Medicare ID - Type Unspecified