Provider Demographics
NPI:1073615506
Name:HOLM, MICHAEL BURTON (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BURTON
Last Name:HOLM
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 1:10350 COLOMA RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-2106
Mailing Address - Country:US
Mailing Address - Phone:916-362-9247
Mailing Address - Fax:916-362-0153
Practice Address - Street 1:10350 COLOMA RD
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-2106
Practice Address - Country:US
Practice Address - Phone:916-362-9247
Practice Address - Fax:916-362-0153
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA289381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATIN 94-277871OtherTAX ID #