Provider Demographics
NPI:1417205873
Name:FOWLER, JASON ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALAN
Last Name:FOWLER
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 1:419 EUCALYPTUS DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7126
Mailing Address - Country:US
Mailing Address - Phone:909-709-6932
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMPSON ST
Practice Address - Street 2:BLDG. 237
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2942
Practice Address - Country:US
Practice Address - Phone:847-688-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist