Provider Demographics
NPI:1821419979
Name:HOLMES, DEMENTRE (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:DEMENTRE
Middle Name:
Last Name:HOLMES
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11409 N 58TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-3312
Mailing Address - Country:US
Mailing Address - Phone:480-577-7096
Mailing Address - Fax:800-869-4964
Practice Address - Street 1:11409 N 58TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-3312
Practice Address - Country:US
Practice Address - Phone:480-577-7096
Practice Address - Fax:800-869-4964
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2447I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician