Provider Demographics
NPI:1093981011
Name:OWEN DENTAL, PC
Entity Type:Organization
Organization Name:OWEN DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-523-4700
Mailing Address - Street 1:333 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4322
Mailing Address - Country:US
Mailing Address - Phone:208-523-4700
Mailing Address - Fax:
Practice Address - Street 1:333 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4322
Practice Address - Country:US
Practice Address - Phone:208-523-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty