Provider Demographics
NPI:1770705741
Name:FOWLER, NELLY (DENTIST)
Entity type:Individual
Prefix:DR
First Name:NELLY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. 17TH STREET SUITE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706
Mailing Address - Country:US
Mailing Address - Phone:714-558-8077
Mailing Address - Fax:714-558-8804
Practice Address - Street 1:500 WEST 17TH STREET
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706
Practice Address - Country:US
Practice Address - Phone:714-558-8077
Practice Address - Fax:714-558-8804
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist