Healthcare Provider Details

I. General information

NPI: 1801010046
Provider Name (Legal Business Name): MICHAEL NEIL HOLDEN LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25052 104TH AVE SE STE G
KENT WA
98030-6853
US

IV. Provider business mailing address

25052 104TH AVE SE STE G
KENT WA
98030-6853
US

V. Phone/Fax

Practice location:
  • Phone: 253-813-8000
  • Fax: 253-813-8007
Mailing address:
  • Phone: 253-813-8000
  • Fax: 253-813-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN 60153167
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10111220
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: