Healthcare Provider Details

I. General information

NPI: 1902949969
Provider Name (Legal Business Name): PHILLIP DAVID LOWDER D.D.S., M.CL.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 SOUTH SKYINE DRIVE STE 4
IDAHO FALLS ID
83402
US

IV. Provider business mailing address

1002 SHELL FLOWER RD
HENDERSON NV
89074-8049
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-1404
  • Fax: 208-524-1114
Mailing address:
  • Phone: 702-451-4205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3100
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3600-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: