=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144199639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC DENTAL CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1023 N MOUND ST STE D
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-9401
-----------------------------------------------------
Fax | 936-564-3907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1023 N MOUND ST STE D
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75961-4453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-9401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. SIDNEY JACK FOWLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 936-564-9401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------