Provider Demographics
NPI:1518233667
Name:TAYLOR C. FOWLES, DMD, LLC
Entity Type:Organization
Organization Name:TAYLOR C. FOWLES, DMD, LLC
Other - Org Name:EAST BEND DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALECIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOLLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-388-1434
Mailing Address - Street 1:2250 NE PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6063
Mailing Address - Country:US
Mailing Address - Phone:541-388-1434
Mailing Address - Fax:541-388-1293
Practice Address - Street 1:2250 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-388-1434
Practice Address - Fax:541-388-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD10810OtherOREGON DENTAL LICENSE
ORD9910OtherOREGON DENTAL LICENSE
ORD9948OtherOREGON DENTAL LICENSE