Provider Demographics
NPI:1417975772
Name:HOLBROOK, GREGORY S (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MAIN ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4451
Mailing Address - Country:US
Mailing Address - Phone:208-756-2899
Mailing Address - Fax:208-756-4686
Practice Address - Street 1:1301 MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4451
Practice Address - Country:US
Practice Address - Phone:208-756-2899
Practice Address - Fax:208-756-4686
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID006084OtherDELTA DENTAL
ID6A135OtherBLUE CROSS OF IDAHO
ID00087549OtherUNITED CONCORDIA