Healthcare Provider Details

I. General information

NPI: 1679771976
Provider Name (Legal Business Name): M BRETT HOLLIDAY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2007
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 W CORDOVA RD
SANTA FE NM
87505-1825
US

IV. Provider business mailing address

157 W ZIA RD
SANTA FE NM
87505-5750
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-6776
  • Fax:
Mailing address:
  • Phone: 505-820-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD1994
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: