Healthcare Provider Details

I. General information

NPI: 1477123883
Provider Name (Legal Business Name): TYLER JUSTIN BOWEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MONTGOMERY ST STE B
WILLIS TX
77378-8827
US

IV. Provider business mailing address

3511 LAKE LUGANO CIR
KATY TX
77493-4067
US

V. Phone/Fax

Practice location:
  • Phone: 936-701-5010
  • Fax:
Mailing address:
  • Phone: 210-535-7360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37376
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: