Provider Demographics
NPI:1043694912
Name:OWENS, MATHEW (DMD)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:OWENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-956-2665
Mailing Address - Fax:706-657-2958
Practice Address - Street 1:87 S BURNT MILL RD
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-4263
Practice Address - Country:US
Practice Address - Phone:706-620-4494
Practice Address - Fax:706-657-2958
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0150151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003168798AMedicaid
GA003168798BMedicaid
GA003168798CMedicaid