Provider Demographics
NPI:1407863616
Name:HOLMGREN, LAWRENCE SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:SCOTT
Last Name:HOLMGREN
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 1:1004 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-348-8184
Mailing Address - Fax:405-348-5349
Practice Address - Street 1:1004 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-348-8184
Practice Address - Fax:405-348-5349
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
731474414001OtherBLUE CROSS BLUE SHIELD
731474414001OtherBLUE CROSS BLUE SHIELD
U00890Medicare UPIN
OK731474414OtherEMPLOYER IDENTIFICATION NUMBER (EIN)