Provider Demographics
NPI:1164410312
Name:BOWLIN, DAN O (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:O
Last Name:BOWLIN
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 1:13245 KESSLER RD
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:IL
Mailing Address - Zip Code:62914-3101
Mailing Address - Country:US
Mailing Address - Phone:618-734-4400
Mailing Address - Fax:618-734-2884
Practice Address - Street 1:405 2ND ST
Practice Address - Street 2:
Practice Address - City:TAMMS
Practice Address - State:IL
Practice Address - Zip Code:62988
Practice Address - Country:US
Practice Address - Phone:618-747-2391
Practice Address - Fax:618-747-2371
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190152641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019015264Medicaid