MEDICARE: DR. KENNETH SHANE FOWLER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	5326	LA

General Provider Information

NPI Number	:	1518004761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH SHANE FOWLER D.D.S.

Provider Business Mailing Address
First Line	:	4906 AMBASSADOR CAFFERY PKWY BLDG O
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-6962
Country	:	US
Telephone Number	:	337-981-0144
Fax Number	:	337-981-0162

Provider Business Practice Location Address
First Line	:	4906 AMBASSADOR CAFFERY PKWY BLDG O
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-6962
Country	:	US
Telephone Number	:	337-981-0144
Fax Number	:	337-981-0162

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	03/23/2023

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