Healthcare Provider Details

I. General information

NPI: 1790959609
Provider Name (Legal Business Name): JEFFREY F. SOWLE DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 EAST MAIN ST
KENDRICK ID
83537-0160
US

IV. Provider business mailing address

PO BOX 160
KENDRICK ID
83537-0160
US

V. Phone/Fax

Practice location:
  • Phone: 208-289-3221
  • Fax: 208-289-3721
Mailing address:
  • Phone: 208-289-3221
  • Fax: 208-289-3721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number66D1616
License Number StateID

VIII. Authorized Official

Name: DR. JEFFREY F. SOWLE
Title or Position: PRESIDENT
Credential: DDS
Phone: 208-289-3221