Provider Demographics
NPI:1144990227
Name:OWENS, CRYSTAL J
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6976 OLD CUSSETA RD BLDG 4202
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-5431
Mailing Address - Country:US
Mailing Address - Phone:706-544-3176
Mailing Address - Fax:706-545-5228
Practice Address - Street 1:6976 OLD CUSSETA RD BLDG 4202
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5431
Practice Address - Country:US
Practice Address - Phone:706-544-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH15213124Q00000X
ALH.9034-C124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist