Provider Demographics
NPI:1144254004
Name:OWSLEY-BROWN, J. RENA (DMD)
Entity type:Individual
Prefix:
First Name:J.
Middle Name:RENA
Last Name:OWSLEY-BROWN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4549
Mailing Address - Country:US
Mailing Address - Phone:770-461-5500
Mailing Address - Fax:770-461-1033
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:SUITE 204
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4549
Practice Address - Country:US
Practice Address - Phone:770-461-5500
Practice Address - Fax:770-461-1033
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA791041331AMedicaid