Provider Demographics
NPI:1619177169
Name:HOLLAND, KEITH VAUGHN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:VAUGHN
Last Name:HOLLAND
Suffix:
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 1:4114 HERSCHEL ST
Mailing Address - Street 2:SUITE 106A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2206
Mailing Address - Country:US
Mailing Address - Phone:904-389-3694
Mailing Address - Fax:
Practice Address - Street 1:4114 HERSCHEL ST
Practice Address - Street 2:SUITE 106A
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2206
Practice Address - Country:US
Practice Address - Phone:904-389-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDL6827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist