Provider Demographics
NPI:1922189430
Name:FOWLER, LESLIE O (DMD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:O
Last Name:FOWLER
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 1:1563 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27205-9602
Mailing Address - Country:US
Mailing Address - Phone:336-626-4677
Mailing Address - Fax:
Practice Address - Street 1:181 E WARD ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5547
Practice Address - Country:US
Practice Address - Phone:336-629-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC 35471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice