MEDICARE: CRYSTAL J OWENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH15213	FL
2	124Q00000X	Dental Hygienist	H.9034-C	AL

General Provider Information

NPI Number	:	1144990227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL J OWENS

Provider Business Mailing Address
First Line	:	6976 OLD CUSSETA RD BLDG 4202
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5431
Country	:	US
Telephone Number	:	706-544-3176
Fax Number	:	706-545-5228

Provider Business Practice Location Address
First Line	:	6976 OLD CUSSETA RD BLDG 4202
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-5431
Country	:	US
Telephone Number	:	706-544-3176
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2021
Last Update Date	:	09/20/2021

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