Healthcare Provider Details

I. General information

NPI: 1033133384
Provider Name (Legal Business Name): LARRY DWIGHT HOLDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DWIGHT HOLDEN MD, FAPA, INC.

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E GOLDEN EAGLE RD
SANTA FE NM
87506-8223
US

IV. Provider business mailing address

3 E GOLDEN EAGLE RD
SANTA FE NM
87506-8223
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-7476
  • Fax: 505-986-6453
Mailing address:
  • Phone: 505-988-7476
  • Fax: 505-986-6453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2004-0805
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: