Provider Demographics
NPI:1487885505
Name:HOLLIS, KELI ROSE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELI
Middle Name:ROSE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 OLD DEKALB RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3134
Mailing Address - Country:US
Mailing Address - Phone:315-386-2960
Mailing Address - Fax:
Practice Address - Street 1:1956 OLD DEKALB RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3134
Practice Address - Country:US
Practice Address - Phone:315-386-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0545061223G0001X
NY500545061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NY01995615Medicaid