MEDICARE: DR. EDWARD BRIAN FOWLER DDS, MS

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	1223P0300X	Periodontics	30-01-8220	OH
2	1223P0300X	Periodontics	DE00008884	WA

General Provider Information

NPI Number	:	1407836331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD BRIAN FOWLER DDS, MS

Provider Business Mailing Address
First Line	:	5005 N PIEDRAS ST
Second Line	:	U.S. ARMY DENTAL ACTIVITY- FT BLISS
City	:	EL PASO
State	:	TX
Zip	:	79920-5001
Country	:	US
Telephone Number	:	915-742-6001
Fax Number	:	915-568-5174

Provider Business Practice Location Address
First Line	:	5005 N PIEDRAS ST
Second Line	:	U.S. ARMY DENTAL ACTIVITY- FT BLISS
City	:	EL PASO
State	:	TX
Zip	:	79920-5001
Country	:	US
Telephone Number	:	915-742-6001
Fax Number	:	915-568-5174

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	06/07/2016

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