Healthcare Provider Details

I. General information

NPI: 1518978576
Provider Name (Legal Business Name): EDWARD CHARLES BOWLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR BUILDING 3 SUITE 253
LA MESA CA
91942-3020
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BUILDING 3 SUITE 253
LA MESA CA
91942-3020
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-2900
  • Fax:
Mailing address:
  • Phone: 619-461-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number23090
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: