Provider Demographics
NPI:1598800864
Name:FOWLE & FAGIN ORTHODONTICS
Entity Type:Organization
Organization Name:FOWLE & FAGIN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FOWLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-364-0590
Mailing Address - Street 1:27800 MEDICAL CENTER ROAD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6442
Mailing Address - Country:US
Mailing Address - Phone:949-364-0590
Mailing Address - Fax:949-364-0739
Practice Address - Street 1:27800 MEDICAL CENTER ROAD
Practice Address - Street 2:SUITE 155
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6442
Practice Address - Country:US
Practice Address - Phone:949-364-0590
Practice Address - Fax:949-364-0739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty