Provider Demographics
NPI:1265595995
Name:BRENT L HOLMAN DDS PC
Entity type:Organization
Organization Name:BRENT L HOLMAN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-232-1148
Mailing Address - Street 1:2538 UNIVERSITY DR S
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5737
Mailing Address - Country:US
Mailing Address - Phone:701-232-1148
Mailing Address - Fax:701-232-8907
Practice Address - Street 1:2538 UNIVERSITY DR S
Practice Address - Street 2:SUITE A
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5737
Practice Address - Country:US
Practice Address - Phone:701-232-1148
Practice Address - Fax:701-232-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40633Medicaid
ND26296OtherND BLUE CROSS BLUE SHIELD
MN330OtherDELTA DENTAL
MN91799110OtherBLUE CROSS BLUE SHIELD