Provider Demographics
NPI:1508946260
Name:FOWLER, TATUM JOSHUA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TATUM
Middle Name:JOSHUA
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 NOELTON DR
Mailing Address - Street 2:APT. 1
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-7625
Mailing Address - Country:US
Mailing Address - Phone:865-384-5702
Mailing Address - Fax:
Practice Address - Street 1:106 TULSA RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6601
Practice Address - Country:US
Practice Address - Phone:865-482-1881
Practice Address - Fax:865-482-3518
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice