Provider Demographics
NPI:1063038255
Name:LEWIS, BROCK B (DDS)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:B
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 1:2100 S 20TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-2398
Mailing Address - Country:US
Mailing Address - Phone:531-910-7980
Mailing Address - Fax:531-910-7959
Practice Address - Street 1:2100 S 20TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-2398
Practice Address - Country:US
Practice Address - Phone:531-910-7980
Practice Address - Fax:531-910-7959
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7627122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10027767800Medicaid