Healthcare Provider Details

I. General information

NPI: 1255595773
Provider Name (Legal Business Name): BRIAN G HOLMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 E 3900 S SUITE 202
SALT LAKE CITY UT
84124-1474
US

IV. Provider business mailing address

1345 E 3900 S SUITE 202
SALT LAKE CITY UT
84124-1474
US

V. Phone/Fax

Practice location:
  • Phone: 801-278-2819
  • Fax: 801-278-2546
Mailing address:
  • Phone: 801-278-2819
  • Fax: 801-278-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6399028-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: