MEDICARE: DR. BRIAN G HOLMAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6399028-9921	UT

General Provider Information

NPI Number	:	1255595773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN G HOLMAN D.D.S.

Provider Business Mailing Address
First Line	:	1345 E 3900 S
Second Line	:	SUITE 202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1474
Country	:	US
Telephone Number	:	801-278-2819
Fax Number	:	801-278-2546

Provider Business Practice Location Address
First Line	:	1345 E 3900 S
Second Line	:	SUITE 202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1474
Country	:	US
Telephone Number	:	801-278-2819
Fax Number	:	801-278-2546

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2008
Last Update Date	:	07/14/2008

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