Provider Demographics
NPI:1518200088
Name:BOWERSOX, LAUREN ELIZABETH
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:BOWERSOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 HUFF RD NW APT 5059
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-4385
Mailing Address - Country:US
Mailing Address - Phone:678-429-6704
Mailing Address - Fax:
Practice Address - Street 1:1808 POWDER SPRINGS RD SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4150
Practice Address - Country:US
Practice Address - Phone:770-941-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN014870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program