Provider Demographics
NPI:1528022092
Name:BOWEN, LYNN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:R
Last Name:BOWEN
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 1:210 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2233
Mailing Address - Country:US
Mailing Address - Phone:260-463-7006
Mailing Address - Fax:260-463-4135
Practice Address - Street 1:210 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2233
Practice Address - Country:US
Practice Address - Phone:260-463-7006
Practice Address - Fax:260-463-4135
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200956730AMedicaid