Provider Demographics
NPI:1952476483
Name:FOWLER, RONALD VAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:VAN
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:PO BOX 170007
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-0020
Mailing Address - Country:US
Mailing Address - Phone:864-576-8040
Mailing Address - Fax:864-576-1759
Practice Address - Street 1:301 E BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3737
Practice Address - Country:US
Practice Address - Phone:864-576-8040
Practice Address - Fax:864-576-1759
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice