Provider Demographics
NPI:1518004761
Name:FOWLER, KENNETH SHANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SHANE
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 1:4906 AMBASSADOR CAFFERY PKWY BLDG O
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6962
Mailing Address - Country:US
Mailing Address - Phone:337-981-0144
Mailing Address - Fax:337-981-0162
Practice Address - Street 1:4906 AMBASSADOR CAFFERY PKWY BLDG O
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6962
Practice Address - Country:US
Practice Address - Phone:337-981-0144
Practice Address - Fax:337-981-0162
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53261223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics