Healthcare Provider Details

I. General information

NPI: 1043694912
Provider Name (Legal Business Name): MATHEW OWENS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 S BURNT MILL RD
LA FAYETTE GA
30728-4263
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-620-4494
  • Fax: 706-657-2958
Mailing address:
  • Phone: 706-956-2665
  • Fax: 706-657-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015015
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: