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General NPI Number Information
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NPI Number | 1740662766
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Entity Type | Individual
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Provider Name | SAMUEL MATTHEW FOWLER DMD
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Gender | Male
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Dates
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Enumeration Date | 06/25/2015
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Last Update Date | 08/12/2024
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Provider Practice Location Address
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Address Line | 77 NEALY AVE
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City | LANGLEY AFB
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State | VA
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Zip | 23665-2040
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Country | US
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Telephone | 801-837-6021
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Fax |
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Provider Business Mailing Address
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Address Line | 1858 S 800 E
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City | BOUNTIFUL
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State | UT
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Zip | 84010-4142
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Country | US
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Telephone | 801-837-6021
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Fax |
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 0401419024
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License Number State | VA
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