Healthcare Provider Details

I. General information

NPI: 1710176789
Provider Name (Legal Business Name): DR. CAROL EDWARDS OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S. HWY 89
JACKSON WY
83001-0628
US

IV. Provider business mailing address

PO BOX 628 1130 S. HWY 89
JACKSON WY
83001-0628
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3848
  • Fax: 307-733-8978
Mailing address:
  • Phone: 307-733-3848
  • Fax: 307-733-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number698
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: