Provider Demographics
NPI:1790709087
Name:HOLT, BRIAN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:HOLT
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 1:1100 JOHN HARDEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-3161
Mailing Address - Country:US
Mailing Address - Phone:501-982-4520
Mailing Address - Fax:501-982-7450
Practice Address - Street 1:1100 JOHN HARDEN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3161
Practice Address - Country:US
Practice Address - Phone:501-982-4520
Practice Address - Fax:501-982-7450
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
AR31431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR512089OtherUNITED CONCORDIA
AR57017OtherBCBS