MEDICARE: NICHOLAS EVAN BOWERMAN DDS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	10534	SC

General Provider Information

NPI Number	:	1952000812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS EVAN BOWERMAN DDS

Provider Business Mailing Address
First Line	:	1971 N MAIN ST
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-7890
Country	:	US
Telephone Number	:	843-695-9236
Fax Number	:

Provider Business Practice Location Address
First Line	:	3102 N HIGHWAY 17
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-6925
Country	:	US
Telephone Number	:	843-970-7292
Fax Number	:

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

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	07/28/2023

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