Provider Demographics
NPI:1962018424
Name:FOWLER, SYDNEY (DMD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 CHAPELTOWN CIR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5265
Mailing Address - Country:US
Mailing Address - Phone:661-877-7697
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD STE 314
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8632
Practice Address - Country:US
Practice Address - Phone:661-877-7697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice