Provider Demographics
NPI:1013025659
Name:LEWIS, BERNARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30825 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-1903
Mailing Address - Country:US
Mailing Address - Phone:586-751-2900
Mailing Address - Fax:586-751-5224
Practice Address - Street 1:30825 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-1903
Practice Address - Country:US
Practice Address - Phone:586-751-2900
Practice Address - Fax:586-751-5224
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI83731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4017310Medicaid