Healthcare Provider Details

I. General information

NPI: 1144990227
Provider Name (Legal Business Name): CRYSTAL J OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6976 OLD CUSSETA RD BLDG 4202
FORT BENNING GA
31905-5431
US

IV. Provider business mailing address

6976 OLD CUSSETA RD BLDG 4202
FORT BENNING GA
31905-5431
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-3176
  • Fax:
Mailing address:
  • Phone: 706-544-3176
  • Fax: 706-545-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH15213
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH.9034-C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: