Healthcare Provider Details

I. General information

NPI: 1952392052
Provider Name (Legal Business Name): BRODIE LEN BOWMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1640
US

IV. Provider business mailing address

28 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1640
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-2122
  • Fax:
Mailing address:
  • Phone: 850-863-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 16286
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9750
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: