Provider Demographics
NPI:1194886135
Name:HOLMBERG, JON EDVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:EDVIN
Last Name:HOLMBERG
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 1:1837 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3516
Mailing Address - Country:US
Mailing Address - Phone:360-825-2081
Mailing Address - Fax:
Practice Address - Street 1:1837 WELLS ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3516
Practice Address - Country:US
Practice Address - Phone:360-825-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist