Healthcare Provider Details

I. General information

NPI: 1699190835
Provider Name (Legal Business Name): DR. JOHN M OWEN IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 25TH AVE NE SUITE 205
SEATTLE WA
98105-5667
US

IV. Provider business mailing address

167 W MAIN ST
BEDFORD VA
24523-1950
US

V. Phone/Fax

Practice location:
  • Phone: 206-524-1600
  • Fax:
Mailing address:
  • Phone: 540-330-9769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414797
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: