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General NPI Number Information
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NPI Number | 1699966770
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Entity Type | Individual
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Provider Name | BRENDA LYLE FOWLER D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 04/27/2017
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Provider Practice Location Address
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Address Line | 2408 S LAMAR BLVD SUITE 3
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City | OXFORD
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State | MS
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Zip | 38655-5345
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Country | US
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Telephone | 662-513-4619
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Fax | 662-513-5528
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Provider Business Mailing Address
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Address Line | 2408 S LAMAR BLVD SUITE 3
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City | OXFORD
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State | MS
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Zip | 38655-5345
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Country | US
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Telephone | 662-513-4619
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Fax | 662-513-5528
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3912-17
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License Number State | MS
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