Provider Demographics
NPI:1821063058
Name:HOLMES, KATASHIA HICKS
Entity Type:Individual
Prefix:
First Name:KATASHIA
Middle Name:HICKS
Last Name:HOLMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 JAMESON LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8217
Mailing Address - Country:US
Mailing Address - Phone:912-492-8408
Mailing Address - Fax:
Practice Address - Street 1:1367 JAMESON LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8217
Practice Address - Country:US
Practice Address - Phone:912-492-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180176Medicaid
GA199726296EMedicaid
GA199726296FMedicaid
GA199726296AMedicaid