Provider Demographics
NPI:1619991916
Name:HOLDREDGE, DARYL GRANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:GRANT
Last Name:HOLDREDGE
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 1:1231 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3007
Mailing Address - Country:US
Mailing Address - Phone:920-437-7188
Mailing Address - Fax:
Practice Address - Street 1:1231 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3007
Practice Address - Country:US
Practice Address - Phone:920-437-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist