Provider Demographics
NPI:1053678516
Name:FLORENCE DENTAL CLINIC
Entity Type:Organization
Organization Name:FLORENCE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT FLORENCE DENTAL CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-997-3535
Mailing Address - Street 1:PO BOX 2956
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-0167
Mailing Address - Country:US
Mailing Address - Phone:541-997-3535
Mailing Address - Fax:541-997-3186
Practice Address - Street 1:2750 KINGWOOD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97430
Practice Address - Country:US
Practice Address - Phone:541-997-3535
Practice Address - Fax:541-997-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-77541223G0001X
ORD-91551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty