Provider Demographics
NPI:1649489212
Name:HOLMES, BRAD L (DDS)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:L
Last Name:HOLMES
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 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:STE. #150
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-375-3910
Mailing Address - Fax:801-375-4001
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:STE. #150
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-375-3910
Practice Address - Fax:801-375-4001
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145724-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics