Provider Demographics
NPI:1902828767
Name:SOWLE, JEFFREY F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:F
Last Name:SOWLE
Suffix:
Gender:M
Credentials:DDS
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 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
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66D16161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00246200Medicaid
WA5037569Medicaid