Provider Demographics
NPI:1548942162
Name:HOLMGREN, AUSTIN BRADLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:BRADLEY
Last Name:HOLMGREN
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 1:2741 WATERS PLACE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-5305
Mailing Address - Country:US
Mailing Address - Phone:320-212-6296
Mailing Address - Fax:
Practice Address - Street 1:1905 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-5401
Practice Address - Country:US
Practice Address - Phone:865-983-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN122801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice