Provider Demographics
NPI:1841303765
Name:OWENS, JEREL NATHANIEL (DMD)
Entity type:Individual
Prefix:
First Name:JEREL
Middle Name:NATHANIEL
Last Name:OWENS
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 1:15400 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3724
Mailing Address - Country:US
Mailing Address - Phone:313-835-5990
Mailing Address - Fax:313-835-5920
Practice Address - Street 1:15400 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3724
Practice Address - Country:US
Practice Address - Phone:313-835-5990
Practice Address - Fax:313-835-5920
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI88183OtherDELTA DENTAL
MI11293190OtherCAQH
MI4718431Medicaid