Provider Demographics
NPI:1922269331
Name:JEFFREY W BOWMAN DMD PC
Entity Type:Organization
Organization Name:JEFFREY W BOWMAN DMD PC
Other - Org Name:GRAND TETON DENTEAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER - DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WILDAN
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-787-2323
Mailing Address - Street 1:741 S 50 W
Mailing Address - Street 2:SUITE A
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5345
Mailing Address - Country:US
Mailing Address - Phone:208-787-2323
Mailing Address - Fax:
Practice Address - Street 1:741 S 50 W
Practice Address - Street 2:SUITE A
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-5345
Practice Address - Country:US
Practice Address - Phone:208-787-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty