Provider Demographics
NPI:1699789537
Name:FOWLER, D'WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:D'WAYNE
Middle Name:
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 1:326 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-3397
Mailing Address - Country:US
Mailing Address - Phone:706-635-7453
Mailing Address - Fax:706-276-2833
Practice Address - Street 1:326 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3397
Practice Address - Country:US
Practice Address - Phone:706-635-7453
Practice Address - Fax:706-276-2833
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice