Provider Demographics
NPI:1336125384
Name:HOLT, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:HOLT
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 1:2309 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2286
Mailing Address - Country:US
Mailing Address - Phone:806-783-0520
Mailing Address - Fax:806-783-0674
Practice Address - Street 1:2309 YORK AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2286
Practice Address - Country:US
Practice Address - Phone:806-783-0520
Practice Address - Fax:806-783-0674
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15567207L00000X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0902165Medicaid
TX75-2277547OtherFEDERAL TAX ID
TXK53HOtherBLUE CROSS BLUE SHIELD
TX0902165Medicaid