Provider Demographics
NPI:1124199237
Name:LEWIS, DAVID M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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 1:317 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1608
Mailing Address - Country:US
Mailing Address - Phone:208-888-2055
Mailing Address - Fax:208-895-0583
Practice Address - Street 1:3175 S MERIDIAN RD STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9267
Practice Address - Country:US
Practice Address - Phone:208-888-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806916200Medicaid