Provider Demographics
NPI:1316474646
Name:FOWLER, STACY MICHELLE (RDH, LAP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:RDH, LAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4583 GRINDE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-8043
Mailing Address - Country:US
Mailing Address - Phone:406-403-1159
Mailing Address - Fax:
Practice Address - Street 1:4583 GRINDE RD
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-8043
Practice Address - Country:US
Practice Address - Phone:406-403-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1109124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty