Provider Demographics
NPI:1174649214
Name:LEWIS, WENDEL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:WENDEL
Middle Name:JOHN
Last Name:LEWIS
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 1:130 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1827
Mailing Address - Country:US
Mailing Address - Phone:208-356-4132
Mailing Address - Fax:208-356-9340
Practice Address - Street 1:130 W MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1827
Practice Address - Country:US
Practice Address - Phone:208-356-4132
Practice Address - Fax:208-356-9340
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD15651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice