Provider Demographics
NPI:1902414311
Name:BOWEN, SAVANNAH LAINE
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:LAINE
Last Name:BOWEN
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 1:1316 MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1646
Mailing Address - Country:US
Mailing Address - Phone:507-376-5525
Mailing Address - Fax:
Practice Address - Street 1:1316 MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1646
Practice Address - Country:US
Practice Address - Phone:507-376-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14427122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist