Provider Demographics
NPI:1629088547
Name:FOWLER, JASON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:4200 BRYANT IRVIN RD STE 109
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4212
Mailing Address - Country:US
Mailing Address - Phone:817-731-6386
Mailing Address - Fax:817-763-0534
Practice Address - Street 1:4200 BRYANT IRVIN RD STE 109
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-4212
Practice Address - Country:US
Practice Address - Phone:817-731-6386
Practice Address - Fax:817-763-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice