Provider Demographics
NPI:1164729851
Name:LYNN R BOWEN DDS PC
Entity Type:Organization
Organization Name:LYNN R BOWEN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-463-7006
Mailing Address - Street 1:210 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2233
Mailing Address - Country:US
Mailing Address - Phone:260-463-7006
Mailing Address - Fax:260-463-4135
Practice Address - Street 1:210 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2233
Practice Address - Country:US
Practice Address - Phone:260-463-7006
Practice Address - Fax:260-463-4135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008550A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200956730AMedicaid