Provider Demographics
NPI:1588608616
Name:HOLTZEN, RICHARD FREDERICK JOHN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FREDERICK JOHN
Last Name:HOLTZEN
Suffix:III
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 1:805 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2104
Mailing Address - Country:US
Mailing Address - Phone:406-381-6845
Mailing Address - Fax:
Practice Address - Street 1:805 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2104
Practice Address - Country:US
Practice Address - Phone:406-381-6845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3332-S228174400000X
CA1010081223S0112X
MT24311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202076Medicaid
NV002202076Medicaid
NVV38468Medicare PIN