Provider Demographics
NPI:1538257498
Name:FOWLER, MATTHEW A (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:FOWLER
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 1:347 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-468-9699
Mailing Address - Fax:208-461-9024
Practice Address - Street 1:347 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2856
Practice Address - Country:US
Practice Address - Phone:208-468-9699
Practice Address - Fax:208-461-9024
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3264-EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics