Provider Demographics
NPI:1073754024
Name:FOWLER MEMORIAL FREE DENTAL CLINIC
Entity Type:Organization
Organization Name:FOWLER MEMORIAL FREE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNAMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLIVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:608-558-2948
Mailing Address - Street 1:N3150 HIGHWAY 81
Mailing Address - Street 2:SUITE B-14
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-9397
Mailing Address - Country:US
Mailing Address - Phone:608-328-9404
Mailing Address - Fax:
Practice Address - Street 1:N3150 HIGHWAY 81
Practice Address - Street 2:SUITE B-14
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-9397
Practice Address - Country:US
Practice Address - Phone:608-328-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty