Healthcare Provider Details

I. General information

NPI: 1649489212
Provider Name (Legal Business Name): BRAD L. HOLMES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 N UNIVERSITY AVE STE. #150
PROVO UT
84604-2721
US

IV. Provider business mailing address

1355 N UNIVERSITY AVE STE. #150
PROVO UT
84604-2721
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-3910
  • Fax: 801-375-4001
Mailing address:
  • Phone: 801-375-3910
  • Fax: 801-375-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number145724-9922
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: