Healthcare Provider Details

I. General information

NPI: 1235390345
Provider Name (Legal Business Name): LOWDER ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 E 17TH STREET
IDAHO ID
83403
US

IV. Provider business mailing address

1410 E 17TH STREET
IDAHO ID
83403
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-4552
  • Fax:
Mailing address:
  • Phone: 208-522-4552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3600OR
License Number StateID

VIII. Authorized Official

Name: DR. PHILLIP DAVID LOWDER
Title or Position: MANAGER
Credential: D.D.S. M.CL.D.
Phone: 208-569-8980