Provider Demographics
NPI:1316141518
Name:OWENS, SALLY ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ELIZABETH
Last Name:OWENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ELIZABETH
Other - Last Name:SIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2308 WYATT AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3635
Mailing Address - Country:US
Mailing Address - Phone:715-341-5441
Mailing Address - Fax:715-341-4752
Practice Address - Street 1:2308 WYATT AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3635
Practice Address - Country:US
Practice Address - Phone:715-341-5441
Practice Address - Fax:715-341-4752
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33608800Medicaid
190000964OtherMEDICARE PTAN