1134886062 NPI number — RYAN S. HOLBROOK, DMD, P.A.

Table of content: (NPI 1134886062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134886062 NPI number — RYAN S. HOLBROOK, DMD, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RYAN S. HOLBROOK, DMD, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134886062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5565 NEW COVINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34233-5212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-265-9507
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 CAPRI ISLES BLVD UNIT 1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34292-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-484-3885
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLBROOK
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
941-484-3885

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)