Provider Demographics
NPI:1760633747
Name:JEREL OWENS D.M.D., P.C.
Entity Type:Organization
Organization Name:JEREL OWENS D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREL
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PC
Authorized Official - Phone:313-273-0640
Mailing Address - Street 1:15344 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3722
Mailing Address - Country:US
Mailing Address - Phone:313-273-0640
Mailing Address - Fax:313-273-0118
Practice Address - Street 1:15344 W. MCNICHOLS
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3722
Practice Address - Country:US
Practice Address - Phone:313-273-0640
Practice Address - Fax:313-273-0118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEREL N OWENS D.M.D., P. C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI114441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4057226Medicaid