Provider Demographics
NPI:1699190835
Name:OWEN, JOHN M IV
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:OWEN
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-1950
Mailing Address - Country:US
Mailing Address - Phone:540-330-9769
Mailing Address - Fax:
Practice Address - Street 1:4915 25TH AVE NE
Practice Address - Street 2:SUITE 205
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5667
Practice Address - Country:US
Practice Address - Phone:206-524-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014147971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice