Provider Demographics
NPI:1689016206
Name:SUE A. MINNEMAN-FOWLER, DDS, PLLC
Entity Type:Organization
Organization Name:SUE A. MINNEMAN-FOWLER, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MINNEMAN-FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-743-2521
Mailing Address - Street 1:1002 JENKINS AVENUE
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28555-0418
Mailing Address - Country:US
Mailing Address - Phone:910-743-2521
Mailing Address - Fax:910-743-2531
Practice Address - Street 1:1002 JENKINS ANENUE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28555
Practice Address - Country:US
Practice Address - Phone:910-743-2521
Practice Address - Fax:910-743-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5410122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900050Medicaid