Provider Demographics
NPI:1942331095
Name:FOWLER, JAMES DAVID SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVID
Last Name:FOWLER
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:J. DAVID
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:112 MORGANTOWN ROAD
Mailing Address - Street 2:PO BOX 508
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42135-0508
Mailing Address - Country:US
Mailing Address - Phone:270-586-0606
Mailing Address - Fax:270-586-7070
Practice Address - Street 1:112 MORGANTOWN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-1440
Practice Address - Country:US
Practice Address - Phone:270-586-0606
Practice Address - Fax:270-586-7070
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6319122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6006319500Medicaid
KY4500075900Medicaid