Provider Demographics
NPI:1982779195
Name:FOWLER, SIDNEY JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:JACK
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 US HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-4924
Mailing Address - Country:US
Mailing Address - Phone:903-690-0969
Mailing Address - Fax:
Practice Address - Street 1:1023 N MOUND ST
Practice Address - Street 2:SUITE D
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4491
Practice Address - Country:US
Practice Address - Phone:936-564-9401
Practice Address - Fax:936-564-3907
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120750805Medicaid
TX172282901Medicaid
TXG60111-01OtherCHIPS