Healthcare Provider Details

I. General information

NPI: 1740209808
Provider Name (Legal Business Name): JOHN C HOLMAN III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 GENESEE AVE SUITE 206
SAN DIEGO CA
92117-4900
US

IV. Provider business mailing address

4320 GENESEE AVE SUITE 206
SAN DIEGO CA
92117-4900
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-6210
  • Fax: 858-279-7961
Mailing address:
  • Phone: 858-279-6210
  • Fax: 858-279-7961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number17099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: