Healthcare Provider Details

I. General information

NPI: 1942863196
Provider Name (Legal Business Name): TESSA HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E 31ST AVE
SPOKANE WA
99203-3101
US

IV. Provider business mailing address

611 E 31ST AVE
SPOKANE WA
99203-3101
US

V. Phone/Fax

Practice location:
  • Phone: 360-904-2658
  • Fax:
Mailing address:
  • Phone: 509-315-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE60970889
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: