Healthcare Provider Details

I. General information

NPI: 1861421224
Provider Name (Legal Business Name): MELANIE FOWLER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4906 AMBASSADOR CAFFERY PKWY BLDG O
LAFAYETTE LA
70508-6916
US

IV. Provider business mailing address

4906 AMBASSADOR CAFFERY PKWY BLDG O
LAFAYETTE LA
70508-6916
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-4350
  • Fax: 337-981-4352
Mailing address:
  • Phone: 337-981-4350
  • Fax: 337-981-4352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5402
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: