Healthcare Provider Details

I. General information

NPI: 1619098878
Provider Name (Legal Business Name): WALTER Q BOWLIN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3645 W WATERS AVE
TAMPA FL
33614-2783
US

IV. Provider business mailing address

3411 FORELOCK RD
TARPON SPRINGS FL
34688-9043
US

V. Phone/Fax

Practice location:
  • Phone: 813-933-6228
  • Fax: 813-933-8237
Mailing address:
  • Phone: 727-709-1388
  • Fax: 727-943-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN0013288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: