Provider Demographics
NPI:1437546439
Name:JEREL N OWENS, DMD, PC
Entity Type:Organization
Organization Name:JEREL N OWENS, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREL
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:313-273-0640
Mailing Address - Street 1:15344 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3722
Mailing Address - Country:US
Mailing Address - Phone:313-273-0640
Mailing Address - Fax:313-273-0118
Practice Address - Street 1:15344 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3722
Practice Address - Country:US
Practice Address - Phone:313-273-0640
Practice Address - Fax:313-273-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011444261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1760633747Medicaid