Provider Demographics
NPI:1568597284
Name:HOLMES, MARLON L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARLON
Middle Name:L
Last Name:HOLMES
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:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-0655
Mailing Address - Country:US
Mailing Address - Phone:318-876-3313
Mailing Address - Fax:318-876-3313
Practice Address - Street 1:915 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327
Practice Address - Country:US
Practice Address - Phone:318-876-3313
Practice Address - Fax:318-876-3313
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1845531Medicaid