Provider Demographics
NPI:1699966770
Name:FOWLER, BRENDA LYLE (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LYLE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 S LAMAR BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5345
Mailing Address - Country:US
Mailing Address - Phone:662-513-4619
Mailing Address - Fax:662-513-5528
Practice Address - Street 1:2408 S LAMAR BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5345
Practice Address - Country:US
Practice Address - Phone:662-513-4619
Practice Address - Fax:662-513-5528
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3912-171223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics