Provider Demographics
NPI:1427185503
Name:BOWER, ROY DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:DALE
Last Name:BOWER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 MARC DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4268
Mailing Address - Country:US
Mailing Address - Phone:618-467-2717
Mailing Address - Fax:618-465-4814
Practice Address - Street 1:2716 CORNER CT
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5328
Practice Address - Country:US
Practice Address - Phone:618-465-6268
Practice Address - Fax:618-465-4814
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004395Medicaid