Provider Demographics
NPI:1952183089
Name:HOLMGREN, CODY JOHN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:JOHN
Last Name:HOLMGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 STERLING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-7752
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:
Practice Address - Street 1:6050 STERLING CREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-7752
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014417A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist