Provider Demographics
NPI:1417441767
Name:KEITH HOLM LLC
Entity Type:Organization
Organization Name:KEITH HOLM LLC
Other - Org Name:LITTLE SMILES OF SURPRISE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-251-9767
Mailing Address - Street 1:13915 N DYSART RD STE A1
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-7333
Mailing Address - Country:US
Mailing Address - Phone:623-444-6340
Mailing Address - Fax:623-444-6350
Practice Address - Street 1:13915 N DYSART RD STE A1
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-7333
Practice Address - Country:US
Practice Address - Phone:623-444-6340
Practice Address - Fax:623-444-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7138122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty