Provider Demographics
NPI:1689221079
Name:GRANT J FOWLER D.D.S.
Entity Type:Organization
Organization Name:GRANT J FOWLER D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-2291
Mailing Address - Street 1:815 W PERSIMMON ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3657
Mailing Address - Country:US
Mailing Address - Phone:479-636-2291
Mailing Address - Fax:
Practice Address - Street 1:815 W PERSIMMON ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3657
Practice Address - Country:US
Practice Address - Phone:479-636-2291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty