Provider Demographics
NPI:1124199393
Name:HOLKA, STEPHEN J
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:HOLKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N. BROADWAY STREET
Mailing Address - Street 2:PO BOX 269
Mailing Address - City:OAKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47561-0269
Mailing Address - Country:US
Mailing Address - Phone:812-745-4151
Mailing Address - Fax:
Practice Address - Street 1:100 N. BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:OAKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47561-0269
Practice Address - Country:US
Practice Address - Phone:812-745-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010551A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200357310AMedicaid
IN200435290Medicaid