Provider Demographics
NPI:1699295204
Name:HOLT, STEPHEN THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:THOMAS
Last Name:HOLT
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 1:607 SENECA AVE APT 3R
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 WEST PIERSON ROAD, UNITS B-D
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504
Practice Address - Country:US
Practice Address - Phone:810-789-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI29010227991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program