Healthcare Provider Details

I. General information

NPI: 1598800864
Provider Name (Legal Business Name): FOWLE & FAGIN ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27800 MEDICAL CENTER ROAD SUITE 155
MISSION VIEJO CA
92691-6442
US

IV. Provider business mailing address

27800 MEDICAL CENTER ROAD SUITE 155
MISSION VIEJO CA
92691-6442
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-0590
  • Fax: 949-364-0739
Mailing address:
  • Phone: 949-364-0590
  • Fax: 949-364-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number24777
License Number StateCA

VIII. Authorized Official

Name: DR. STEVEN DOUGLAS FOWLE
Title or Position: GENERAL PARTNER
Credential: D.D.S.
Phone: 949-364-0590