Provider Demographics
NPI:1073202420
Name:BOWEN, LISA (PHDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOWEN
Suffix:
Gender:F
Credentials:PHDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SUSQUEHANNA AVE
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4912
Mailing Address - Country:US
Mailing Address - Phone:570-446-3062
Mailing Address - Fax:
Practice Address - Street 1:2888 SR 29 S
Practice Address - Street 2:
Practice Address - City:MONROE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18636-7854
Practice Address - Country:US
Practice Address - Phone:570-704-4647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH001369124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist