Provider Demographics
NPI:1396843058
Name:LOWRY, MARCUS (DDS)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:LOWRY
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 1:2275 S EAGLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5078
Mailing Address - Country:US
Mailing Address - Phone:208-855-5045
Mailing Address - Fax:
Practice Address - Street 1:2275 S EAGLE RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5078
Practice Address - Country:US
Practice Address - Phone:208-855-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA571941223X0400X
390200000X
IDD-3908 OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57194OtherCALIFORNIA DENTAL LICENSE NUMBER
IDD-3908-OROtherIDAHO DENTAL LICENSE NUMBER