Healthcare Provider Details

I. General information

NPI: 1811051436
Provider Name (Legal Business Name): JEFFREY NELSON HOLMBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PARK STREET EAST
ANNANDALE MN
55302-0370
US

IV. Provider business mailing address

300 PARK STREET EAST PO BOX 370
ANNANDALE MN
55302-0370
US

V. Phone/Fax

Practice location:
  • Phone: 320-274-8555
  • Fax: 320-274-2851
Mailing address:
  • Phone: 320-274-8555
  • Fax: 320-274-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8955
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: