Provider Demographics
NPI:1942993118
Name:FOWLER, CHRISTIAN TODD (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:TODD
Last Name:FOWLER
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 1:1100 NE E ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2369
Mailing Address - Country:US
Mailing Address - Phone:541-479-5505
Mailing Address - Fax:
Practice Address - Street 1:1100 NE E ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2369
Practice Address - Country:US
Practice Address - Phone:541-479-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist