Provider Demographics
NPI:1740662766
Name:FOWLER, SAMUEL MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MATTHEW
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 1:1858 S 800 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4142
Mailing Address - Country:US
Mailing Address - Phone:801-837-6021
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:801-837-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
VA04014190241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program