=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083720700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOMAS E. HOLBROOK DDS PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 N 11TH AVE SUITE 107
-----------------------------------------------------
City | YAKIMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98902-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-457-4532
-----------------------------------------------------
Fax | 509-453-0175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 N 11TH AVE SUITE 107
-----------------------------------------------------
City | YAKIMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98902-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-457-4532
-----------------------------------------------------
Fax | 509-453-0175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TOMAS E HOLBROOK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 509-457-4532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 5434
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------