Provider Demographics
NPI:1417018003
Name:HOLMES CO. BOARD OF MRDD
Entity Type:Organization
Organization Name:HOLMES CO. BOARD OF MRDD
Other - Org Name:HCTC DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:F.
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-674-8045
Mailing Address - Street 1:8001 TOWNSHIP ROAD 574
Mailing Address - Street 2:
Mailing Address - City:HOLMESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44633-9751
Mailing Address - Country:US
Mailing Address - Phone:330-674-8045
Mailing Address - Fax:330-674-5182
Practice Address - Street 1:8001 TOWNSHIP ROAD 574
Practice Address - Street 2:
Practice Address - City:HOLMESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44633-9751
Practice Address - Country:US
Practice Address - Phone:330-674-8045
Practice Address - Fax:330-674-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2280679Medicaid