Provider Demographics
NPI:1376705087
Name:FOWLKES, MATTHEW WAYNE (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:FOWLKES
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3608
Mailing Address - Country:US
Mailing Address - Phone:318-388-2621
Mailing Address - Fax:318-388-2835
Practice Address - Street 1:2003 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3608
Practice Address - Country:US
Practice Address - Phone:318-388-2621
Practice Address - Fax:318-388-2835
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6460204E00000X
MS3464-08 / OS-481-14204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery