Provider Demographics
NPI:1669035655
Name:ROGUE RIVER SLEEP DENTISTRY
Entity Type:Organization
Organization Name:ROGUE RIVER SLEEP DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-818-0492
Mailing Address - Street 1:377 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-5759
Mailing Address - Country:US
Mailing Address - Phone:206-818-0492
Mailing Address - Fax:
Practice Address - Street 1:205 N BERKLEY ST
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612-5015
Practice Address - Country:US
Practice Address - Phone:206-818-0492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty