Healthcare Provider Details

I. General information

NPI: 1750397980
Provider Name (Legal Business Name): CHARLES RAYMOND BOWEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 COURT ST
MIDDLEBURY VT
05753-4450
US

IV. Provider business mailing address

58 COURT ST
MIDDLEBURY VT
05753-4450
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-6344
  • Fax: 802-388-4103
Mailing address:
  • Phone: 802-388-6344
  • Fax: 802-388-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0160000507
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: