Provider Demographics
NPI:1629560248
Name:HOLMES, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N 20TH ST APT 403
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-2573
Mailing Address - Country:US
Mailing Address - Phone:360-631-2884
Mailing Address - Fax:
Practice Address - Street 1:3064 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-278-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001878-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice