Provider Demographics
NPI:1902082415
Name:BERRY HOLLY, GLORIA LAVERN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:LAVERN
Last Name:BERRY HOLLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:LAVERN
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1118
Mailing Address - Street 2:305 MEADOWLAND DR
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278
Mailing Address - Country:US
Mailing Address - Phone:919-732-8584
Mailing Address - Fax:919-732-8545
Practice Address - Street 1:305 MEADOWLAND DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278
Practice Address - Country:US
Practice Address - Phone:919-732-8584
Practice Address - Fax:919-732-8545
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990678Medicaid
NCC50836OtherUPIN