Provider Demographics
NPI:1225670623
Name:ROGUE DENTAL SLEEP SOLUTIONS LLC
Entity Type:Organization
Organization Name:ROGUE DENTAL SLEEP SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-818-0492
Mailing Address - Street 1:124 NE EVELYN AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1427
Mailing Address - Country:US
Mailing Address - Phone:541-936-9456
Mailing Address - Fax:
Practice Address - Street 1:124 NE EVELYN AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1427
Practice Address - Country:US
Practice Address - Phone:206-818-0492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-17
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty