Provider Demographics
NPI:1053920934
Name:LOWRY, TAIS TREVELIN (DMD)
Entity type:Individual
Prefix:DR
First Name:TAIS
Middle Name:TREVELIN
Last Name:LOWRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2570
Mailing Address - Country:US
Mailing Address - Phone:208-874-7302
Mailing Address - Fax:
Practice Address - Street 1:1800 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2570
Practice Address - Country:US
Practice Address - Phone:208-874-7302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD51501223D0001X
IDD-51501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health