Provider Demographics
NPI:1649322074
Name:BOWEN, GARY M II (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:BOWEN
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CANTERBURY CIR
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25043
Mailing Address - Country:US
Mailing Address - Phone:304-965-0520
Mailing Address - Fax:304-587-7425
Practice Address - Street 1:319 MAIN ST.
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043
Practice Address - Country:US
Practice Address - Phone:304-587-7495
Practice Address - Fax:304-587-7524
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 3570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001572Medicaid