Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 4930 | AL |
NPI | 1013005750 |
---|---|
Provider Name | Dr. Michael Holmes SR. |
First Address | Gadsden, AL 35901-5102 |
Second Address | Gadsden, AL 35901-5102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
51516050 | BLUE CROSS BLUE SHIELD (01) | AL |