Provider Demographics
NPI:1245501808
Name:DAVERIN, HOLLY ANN (RDH)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:ANN
Last Name:DAVERIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11102 W 4000N RD
Mailing Address - Street 2:
Mailing Address - City:BONFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60913-7171
Mailing Address - Country:US
Mailing Address - Phone:815-922-7682
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL DRIVE
Practice Address - Street 2:FORT WASHAKIE DENTAL CLINIC
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0128
Practice Address - Country:US
Practice Address - Phone:307-332-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6127124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist