Provider Demographics
NPI:1679786172
Name:LOWE, DEREK WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:WAYNE
Last Name:LOWE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:DEREK
Other - Middle Name:WAYNE
Other - Last Name:LOWE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:570 RIVERSTONE WAY SUITE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-455-4350
Mailing Address - Fax:907-455-4370
Practice Address - Street 1:570 RIVERSTONE WAY SUITE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-455-4350
Practice Address - Fax:907-455-4370
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK115692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13703838Medicaid