Provider Demographics
NPI:1760574461
Name:BOWDOIN, SAMUEL R (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:BOWDOIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5321 W 151ST ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-9637
Mailing Address - Country:US
Mailing Address - Phone:913-851-9969
Mailing Address - Fax:
Practice Address - Street 1:5321 W 151ST ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66224-9637
Practice Address - Country:US
Practice Address - Phone:913-851-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS601461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200005170BMedicaid