Provider Demographics
NPI:1710176789
Name:OWENS, CAROL EDWARDS
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:EDWARDS
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:1130 S. HWY 89
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0628
Mailing Address - Country:US
Mailing Address - Phone:307-733-3848
Mailing Address - Fax:307-733-8978
Practice Address - Street 1:1130 S. HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-0628
Practice Address - Country:US
Practice Address - Phone:307-733-3848
Practice Address - Fax:307-733-8978
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY698122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist