Provider Demographics
NPI:1043662802
Name:OWENS, DEREK EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:EDWARD
Last Name:OWENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 HOLLYHOCK CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2425
Mailing Address - Country:US
Mailing Address - Phone:586-801-3300
Mailing Address - Fax:
Practice Address - Street 1:3030 E MAIN ST STE T1
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-7627
Practice Address - Country:US
Practice Address - Phone:505-325-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist