Provider Demographics
NPI:1043331184
Name:IMHOLTE, RICHARD R (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:IMHOLTE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W MAIN ST
Mailing Address - Street 2:TWIN CITY DENTAL
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1117
Mailing Address - Country:US
Mailing Address - Phone:360-577-1153
Mailing Address - Fax:360-425-1540
Practice Address - Street 1:409 W MAIN ST
Practice Address - Street 2:TWIN CITY DENTAL
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1117
Practice Address - Country:US
Practice Address - Phone:360-577-1153
Practice Address - Fax:360-425-1540
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA47541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5500905OtherWA STATE D.S.H.S.