Provider Demographics
NPI:1043362452
Name:HOLM, CARL B (DDS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:B
Last Name:HOLM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E CEDAR ST STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3709
Mailing Address - Country:US
Mailing Address - Phone:208-233-2525
Mailing Address - Fax:208-233-2523
Practice Address - Street 1:350 E CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3709
Practice Address - Country:US
Practice Address - Phone:208-233-2525
Practice Address - Fax:208-233-2523
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-33261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
04083OtherBLUESHIELD OF ID
ID82029OtherDELTA DENTAL OF IDAHO
977709OtherBSPA UNITED CONCORDIA
6B471OtherBLUECROSS OF ID