Provider Demographics
NPI:1699069047
Name:FOWLER, STEPHEN MATTHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
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 1:2937 ESSARY DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-2465
Mailing Address - Country:US
Mailing Address - Phone:865-686-0050
Mailing Address - Fax:865-686-0053
Practice Address - Street 1:2937 ESSARY DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-2465
Practice Address - Country:US
Practice Address - Phone:865-686-0050
Practice Address - Fax:865-686-0053
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92801223G0001X
KY9147122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531900Medicaid