1528121258 NPI number — DR. BRENT L HOLMAN DDS

Table of content: DR. BRENT L HOLMAN DDS (NPI 1528121258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528121258 NPI number — DR. BRENT L HOLMAN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMAN
Provider First Name:
BRENT
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1528121258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2538 UNIVERSITY DR S
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-5737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-232-1148
Provider Business Mailing Address Fax Number:
701-232-8907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2538 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-1148
Provider Business Practice Location Address Fax Number:
701-232-8907
Provider Enumeration Date:
12/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  1587 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26296 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 330 . This is a "DELTA DENTAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 91799110 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 370720200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40633 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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