Provider Demographics
NPI:1962789842
Name:BOWERS ORTHODONTIC SPECIALISTS
Entity type:Organization
Organization Name:BOWERS ORTHODONTIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:309-663-0415
Mailing Address - Street 1:9 HEARTLAND DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7732
Mailing Address - Country:US
Mailing Address - Phone:309-663-0415
Mailing Address - Fax:309-661-0685
Practice Address - Street 1:9 HEARTLAND DR
Practice Address - Street 2:SUITE A
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7732
Practice Address - Country:US
Practice Address - Phone:309-663-0415
Practice Address - Fax:309-661-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.023201261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019013689Medicaid
IL021.001647OtherORTHODONTIC LICENSE
IL019.023201OtherDENTAL LICENSE
IL37-1312850OtherEIN