=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669035655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGUE RIVER SLEEP DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 N BERKLEY ST
-----------------------------------------------------
City | COUNCIL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83612-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-818-0492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 AIRPORT RD
-----------------------------------------------------
City | WEISER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83672-5759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-818-0492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | MICHAEL AARON HOLM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 206-818-0492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------