Provider Demographics
NPI:1205566239
Name:BOWLES, DANEISHA TAMARA
Entity type:Individual
Prefix:
First Name:DANEISHA
Middle Name:TAMARA
Last Name:BOWLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-1714
Mailing Address - Country:US
Mailing Address - Phone:804-662-0528
Mailing Address - Fax:
Practice Address - Street 1:3904 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-1714
Practice Address - Country:US
Practice Address - Phone:804-233-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401418349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program