Provider Demographics
NPI:1841250529
Name:HOLMES, DOUG EARL (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:DOUG
Middle Name:EARL
Last Name:HOLMES
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 E. PINON FRONTAGE RD.
Mailing Address - Street 2:BLDG #200
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5061
Mailing Address - Country:US
Mailing Address - Phone:505-599-9359
Mailing Address - Fax:505-599-8177
Practice Address - Street 1:2650 E. PINON FRONTAGE RD.
Practice Address - Street 2:BLDG #200
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5061
Practice Address - Country:US
Practice Address - Phone:505-599-9359
Practice Address - Fax:505-599-8177
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD19251223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000R9148Medicaid