Provider Demographics
NPI:1790959609
Name:JEFFREY F. SOWLE DDS PA
Entity Type:Organization
Organization Name:JEFFREY F. SOWLE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:SOWLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-289-3221
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:KENDRICK
Mailing Address - State:ID
Mailing Address - Zip Code:83537-0160
Mailing Address - Country:US
Mailing Address - Phone:208-289-3221
Mailing Address - Fax:208-289-3721
Practice Address - Street 1:601 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDRICK
Practice Address - State:ID
Practice Address - Zip Code:83537-0160
Practice Address - Country:US
Practice Address - Phone:208-289-3221
Practice Address - Fax:208-289-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66D16161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002462000Medicaid
WA5037569Medicaid