Provider Demographics
NPI:1447532411
Name:HOLM, PETER M (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
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 1:120 NORTH BROADWAY NE, SUITE B
Mailing Address - Street 2:GOOD SAMARITAN DENTAL CLINIC
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906
Mailing Address - Country:US
Mailing Address - Phone:507-424-4199
Mailing Address - Fax:
Practice Address - Street 1:120 NORTH BROADWAY NE, SUITE B
Practice Address - Street 2:GOOD SAMARITAN DENTAL CLINIC
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906
Practice Address - Country:US
Practice Address - Phone:507-424-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND64491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice