Healthcare Provider Details

I. General information

NPI: 1528121258
Provider Name (Legal Business Name): BRENT L HOLMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2006
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2538 UNIVERSITY DR S SUITE A
FARGO ND
58103-5737
US

IV. Provider business mailing address

2538 UNIVERSITY DR S SUITE A
FARGO ND
58103-5737
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-1148
  • Fax: 701-232-8907
Mailing address:
  • Phone: 701-232-1148
  • Fax: 701-232-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1587
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier26296
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier330
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerDELTA DENTAL
# 3
Identifier91799110
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBLUE CROSS BLUE SHIELD
# 4
Identifier370720200
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 5
Identifier40633
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: