Provider Demographics
NPI:1790857480
Name:HOLM, STACEY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:R
Last Name:HOLM
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 1:2231 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3831
Mailing Address - Country:US
Mailing Address - Phone:916-784-6300
Mailing Address - Fax:916-784-6343
Practice Address - Street 1:2231 DOUGLAS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3831
Practice Address - Country:US
Practice Address - Phone:916-784-6300
Practice Address - Fax:916-784-6343
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA384271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice