Provider Demographics
NPI:1487212981
Name:GOWELL, ELIZA JANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELIZA
Middle Name:JANE
Last Name:GOWELL
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 1:2 LIBERTY SQ FL 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4884
Mailing Address - Country:US
Mailing Address - Phone:617-542-8808
Mailing Address - Fax:
Practice Address - Street 1:104 MILK STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109
Practice Address - Country:US
Practice Address - Phone:617-542-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859354122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN1859354OtherDPH