Provider Demographics
NPI:1427364439
Name:FOWLES, KELLI RENE (DMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:RENE
Last Name:FOWLES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 NE PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6063
Mailing Address - Country:US
Mailing Address - Phone:541-388-1434
Mailing Address - Fax:541-388-1293
Practice Address - Street 1:2250 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6063
Practice Address - Country:US
Practice Address - Phone:541-388-1434
Practice Address - Fax:541-388-1293
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8296732-9922122300000X
NVLL-224-101223G0001X
ORD9948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice