Healthcare Provider Details

I. General information

NPI: 1043621188
Provider Name (Legal Business Name): KIWUNA OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MANHEIM AVE
BRIDGETON NJ
08302-2139
US

IV. Provider business mailing address

53 S LAUREL ST
BRIDGETON NJ
08302-1946
US

V. Phone/Fax

Practice location:
  • Phone: 856-451-4700
  • Fax: 856-455-3144
Mailing address:
  • Phone: 856-451-4700
  • Fax: 856-794-7183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number22HI01023500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: