Provider Demographics
NPI:1568545788
Name:HOLMES, RICHARD MARK (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:HOLMES
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 INDIAN TRAIL RD S
Mailing Address - Street 2:PO BOX 338
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9669
Mailing Address - Country:US
Mailing Address - Phone:704-821-7222
Mailing Address - Fax:704-821-4310
Practice Address - Street 1:136 INDIAN TRAIL RD S
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9669
Practice Address - Country:US
Practice Address - Phone:704-821-7222
Practice Address - Fax:704-821-4310
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC60391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994009Medicaid
NC94009OtherBC BS PROVIDER ID NUMBER