Healthcare Provider Details

I. General information

NPI: 1649809583
Provider Name (Legal Business Name): JASON MICHAEL HOLTMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 SW EMKAY DR STE 100
BEND OR
97702-3598
US

IV. Provider business mailing address

77 NW MCKAY AVE
BEND OR
97703-2523
US

V. Phone/Fax

Practice location:
  • Phone: 541-383-0754
  • Fax: 541-383-8218
Mailing address:
  • Phone: 919-264-8368
  • Fax: 541-383-8128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11523
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD11523
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11523
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: